|Year : 2017 | Volume
| Issue : 1 | Page : 3-5
Cadaver skin donation and skin bank
Dr. Gore's Clinic, Sion and; Zen Clinic, Zen Hospital, Chembur; Former Chief and Professor of Surgery, LTM Medical College and General Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||13-Dec-2017|
20, Shreyas, Udayagiri CHS, V.N. Purav Marg, Deonar, Mumbai 400088
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gore M. Cadaver skin donation and skin bank. Indian J Burns 2017;25:3-5
In this article, I plan to share my experience of establishing the first cadaver allograft skin bank in India and the introduction of cadaver skin donation to the Indian society in the year 2000.
Though the first allograft skin bank was established at Bewerwick, Holland, in 1952; such a facility was introduced in India only in the year 2000. The skin and tissue banks existing at Wadia hospital and Tata Memorial hospital in Mumbai prior to this were preserving excess balance skin grafts from patients and skin grafts from amputed extremities. This delay in establishing cadaver skin allograft bank was due to multiple reasons in my opinion—the extremely high mortality rate in patients with burns, a poor understanding of multidisciplinary care required to improve salvage rate, the application of comfort care concept to large burns, which was often interpreted as a neglect of care by those responsible for the delivery of care and general apathy toward burn care. Very few burn units existed at that time (around 1980), and most of these restricted their admissions to burn victims with salvageable burn extent, giving no hopes to large burns. This meant that the role of general surgeons was reduced to the signing of death certificates, and one can imagine how frustrating, demoralising, and depressing this can be. Unfortunately, this status still continues in many teaching institutions. It is obvious that in such a situation, patients with more that 30–35% total body surface area (TBSA) burns were rarely salvaged, and so the need for skin allografts was never perceived. Sadly even today, very few burn centres in India calculate and declare the lethal area 50 (LA50) levels; therefore, nobody knows the salvage rates in different centres.
The burn unit at Lokmanya Tilak Municipal General Hospital (LTMGH) was established by the then Chief of General Surgery, Professor S. V. Nadkarni, in 1983 and continues to be managed by the General Surgery department till date. I was entrusted with the complete responsibility of burn unit in 1989 with dedicated operation time and one Assistant Professor and two surgical residents. Shortly, the burn team extended the care to all patients with burns irrespective of age, sex, and the extent of burn. The LA50 was 35% TBSA burns at that time with about 800 admissions every year. The team included a microbiologist, physiotherapist, occupational therapist, dietician, medical social workers, nursing staff, and helpers; in addition, physician, anaesthesiologist, obstetrician, paediatrician, and psychiatrist were involved as and when needed. The team was enthusiastic, enterprising, and imaginative. All patients with burns irrespective of the extent of injury were treated with the intention to salvage, and no thought of comfort care was ever entertained. Infection control, dressing protocol, antibiotic policy, nutritional support, early burn wound excision, and closure with available skin autografts, all helped in improving the salvage rate to LA50 of 50% TBSA burns by 1995.
At this stage, the need for skin substitutes was acutely perceived for the salvage of patients with burn extent exceeding 40–45% TBSA. We did collaborate with the National Centre for Cell Sciences (NCCS), Pune and, for the first time in India in 1995, we used cultured epithelia (CEA) on a young 16-year-old patient with 65% burns. The team managed to salvage her not because of CEA but with the use of skin allografts from her father. Greatly expensive CEA was still in the research phase and, therefore, unsuitable for routine use. Allografts from living donors were available for children and occasionally for males with burns, but never for young females with burns. Young females formed the largest share (70%) of our patients. With a paucity of resources and the poor availability of synthetic skin substitutes as well as xenografts, skin allografts from cadavers was the only possible solution. I had spent some time at Euro Skin Bank at Bewerwick and the skin bank at Hvidovre in Denmark in 1990. I was duly impressed by the positive effect of skin allografts in the salvage of patients even with 97% burns. In 1998, I spent very valuable time at University of Texas Medical Branch (UTMB) tissue bank at Galveston, USA. I had obtained significant information from these three facilities. Therefore, the efforts to establish cadaver skin allograft bank began in early 1999.
Space was available in the Department of Surgery. Procuring equipment was not a big issue, as some was already received from NCCS under technology transfer program for CEA laboratory, and the remaining was very kindly donated by Sunday Friends—a NGO associated with burn care for several years. In collaboration with Dr. Daksha Pandit of the Microbiology department and Dr. Pritam Phatnani of Forensic Medicine department, various proformas for records and consent form were prepared. The equipment and protocol for graft harvesting and preservation protocols were finalised. All the surgical residents were trained in necessary procedures and protocols.
The main hurdle was to obtain permission from the appropriate authority of the state for harvesting skin allografts from cadaver donors. I had procured the Bombay Anatomy Act of 1949 under which the heart valve bank was already functional at Lokmanya Tilak Municipal Medical College (thanks to Dr. Chaukar and Dr. Patwardhan of the Department of Cardiovascular and Thoracic Surgery). Though Human Organ Transplantation Act was in existence, it did not include tissues then. By definition, organ is one that cannot regenerate when removed, but tissue is that group of cells that can regenerate after removal. Therefore, though full-thickness skin is an organ, split-thickness skin graft is a tissue. Using this argument and the Act, I drafted an appropriate letter addressed to the appropriate authority of the state of Maharashtra. Dr. Gujar and myself pursued this matter for over 6 months, and, finally, the authority gave us a letter stating that it had no objection for this venture if the Dean of the institution was willing. The Dean Dr. Fernandez, a pioneer in establishing the breast milk bank, was already convinced and willing. Therefore, we were finally ready to start the LTMGH skin allograft bank—the first in India, which was inaugurated on April 24, 2000 on the foundation day of the institution.
The next challenge was to create awareness about skin donation after death, because this initiative also marked the introduction of this concept to the Indian society. Brochures were ready; posters were displayed in the hospital. I personally conducted more than 150 awareness programs throughout the city of Mumbai—sometimes even for the audience of two individuals. The regular attendees were members of Sunday Friends. I established collaboration with groups promoting body donation. I wrote articles for magazines and newspapers in different languages. I truly appreciate the support extended by the print media. The surgical and medical residents, lecturers, and other staff members were trained in counselling, because maximum deaths happen in these two specialities. With an average number of deaths in the hospital being 10 every day, I expected at least one suitable donor every day. The other municipal medical institutes did not participate in this venture at all. Probably they did not perceive the need for skin allografts then. Therefore, the number of donations received by the end of year 2006 was 56. Obviously, the strategy of hospital-based counselling was not working. Some seniors in the field of burn care had actually opposed this concept in print media; probably they did not come across large burns in large numbers.
With active help from Sunday Friends, I decided to change the strategy from hospital-based to society-based counselling. These friends already knew almost as much as I knew about skin donation after death and its utility for saving the lives of burn victims. I sorted out all the queries that they had and started this approach in the year 2007. And it worked! The donations increased significantly, and this practice of society-based counselling has now been adopted by all other skin banks that were started much later and in the private sector.
From 2007 to date, the skin bank has received more than 1450 skin donations from cadavers. More than 66% of these are home-based retrievals and are procured within 2–4 h of death. The Sunday Friends include few general practitioners and many laypersons. Besides counselling, they also arrange transport for the procurement team, because the hospital ambulance is often unavailable. The surgical residents are doing an excellent job with great commitment, and despite a heavy workload in patient care, the procurement team leaves within 20 min of receiving the call during any time of day or night. The nursing staff ensures that the drum with equipment is kept ready all the time. The Microbiology department plays its important role without delay. The record assistant in the Department of Surgery maintains the record of donors as well as grafts and its recipients. I am no longer a part of the skin bank, because I retired 7 years ago; the residents change frequently, nursing staff rotates, microbiologists get transferred, but the bank is functioning as smoothly and with the same dedication. Please note that no extra person has ever been employed for the skin bank. All financial shortfalls are taken care through donations.
Sadly, the majority of the Additional Municipal Commissioners (AMC) and Municipal Commissioners were completely unaware of the existence of this notable activity though it was detailed in the administrative report of the institution every year. My personal efforts to make these authorities aware of the fact that this is a rare activity in municipal institutions and carries the credit of introducing a completely new concept to the Indian society for the first time have failed to such an extent that a noted AMC just did not attend the 10th anniversary function of the skin bank in 2010 despite prior approval! Well, I worked and have trained my staff and colleagues to continue the good work for the sake of the patients and not for any authorities or accolades. We have proved and published the benefits of the use of cadaver skin allografts for salvaging patients with very large burns—the largest being one with 85% TBSA burns. The LA50 level achieved in 2009 was 65%. We yet have a long way to go, but we are certainly progressing in the right direction that too in a public hospital with limited resources, no extra staff, and no monetary gains!
This experience has convinced me that the easy availability of the adequate supply of cadaver allograft skin contributes significantly to the improved survival probability of patients with large burns without dependence and the limitations of living skin allograft donors. This is particularly applicable to the patients with large burns from low socioeconomic class in public hospitals. It is not difficult to establish and successfully manage this facility in a medical college setting where the necessary departments and most of the equipments already exist or can be easily procured. The need is to have a team of dedicated and committed persons. Financial assistance in the form of donations is not difficult to obtain if the transparency and reliability of the team is apparent. Many social organizations are ready to conduct the counselling. One such bank can be established in every city with affiliated collection centres and with trained personnel as required by a leader with drive, initiative, and a strong support team. As the number of government medical colleges is significant in Maharashtra, I did approach the heath secretary of the Maharashtra government, three different individuals at three different times. However, I failed to get any response. Somebody else may succeed. So let us keep trying!
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.