Clinical Experience of Omega 3 Fish Graft in Full Thickness Wounds

March - April 2023

Dr Ariel M. Aballay Director, West Penn Burn Center Pittsburgh PA, United States

Clinical Experience of Omega 3 Fish

Graft in Full Thickness Wounds

Editorial Summary

This article is an overview of a case series which examines how decellularized intact fish skin grafts facilitate the healing process in full thickness burn injuries, and describes over time its integration into the wound during follow up after application. Historically, options for reconstruction include various xenografts as well as allografts. Omega3 fatty acids (EPA and DHA) are known for their anti-inflammatory properties. Fish skin grafts have been well established in the management of other challenging clinical scenarios.1-5

Introduction

Current treatments of partial and full thickness burns include various xeno and allografts. Allografts (cadaveric skin) will need to be removed and mammalian derived acellular grafts need harsh processing to decrease the risk of viral disease transmission. Recent advances in technology have made it possible to process fish sourced tissue with a more gentle process, making it safe for medical applications while preserving its intrinsic structure and biological benefits.

Previously published clinical trials showed that full-thickness acute wounds treated with fish skin grafts (FSGs) healed significantly faster than wounds treated with porcine tissue.6-8

Methods

In this case series, three burn patients aged 2271 of various ethnicities, with burn wound sizes ranging from 3-19% Total Body Surface Area (TBSA), received FSGs (Omega3 GraftGuide, Kerecis, Ísafjörður, Iceland (Figure 1)) applied post debridement and/ or excision. The fish skin graft effects on wound healing were evaluated regarding time to wound closure, restoration of barrier function, and complications; level of pain was recorded.

Figure 1: Kerecis Omega3 GraftGuide.

Patient 1: 22 year old male, thermal burn to the back.

The patient, with a past medical history of hydronephrosis, presented with a 19% TBSA thermal burn.

The mechanism of the burn was bonfire-induced, with clothing set alight. The patient presented to the burn center two days post initial injury having had an initial treatment with silver sulfadiazine cream. A single application of fish skin graft resulted in good secondary intention healing for the patient, without the need for an autograft.

2a, 2b: Initial presentation images .

2c: Day 2 pre-treatment images.

2d, 2e: Day 2 post dermabrasion and fish skin graft application.

2f: Post-operative day 4.

2g, 2h: Post-operative day 15.

2i: Post-operative day 21.

Patient 2: 71 year old male, thermal burn to the right arm.

The patient, with a past medical history of hypertension and hyperlipidemia, presented with a 17% TBSA thermal burn due to a lawn tractor.

The patient presented on day 4 post injury after sustaining an explosion after hitting a gas line.

At the 1 year follow up visit, skin matching is significantly improved; the skin quality is soft, flat and pliable, with minimum itching. There was excellent range of movement with no limitation.

3a, 3b: Initial presentation 4 days post burn injury, prior to fish skin graft application.

3c, 3d: Post-operative day 3.

3e, 3f: Post-operative day 10.

3g, 3h: Post-operative day 60.

3i, 3j: Follow up, 9 months; no itching or pain, flat with small areas of hypertrophy.

Clinical Experience of Omega 3 Fish Graft in Full Thickness Wounds

Patient 3: 65 year old female, scald burn.

The patient had inflammatory arthritis and rheumatoid arthritis, chronic kidney disease stage 3, obesity and pulmonary valve dysfunction, and concurrent small cell carcinoma stage IV, and was undergoing chemotherapy.

The patient presented on day 10 post injury, with a 3% TBSA scald burn, previous treatment was standard of care and Collagenase SantylTM (Smith & Nephew, London, United Kingdom). Patient was discharged from the practice due to follow up limitations and chemotherapy treatments. During follow up (1 year after treatment), patient had improved pigment matching, skin was soft and pliable with no itching, and showed a full range of motion without limitation.

4a: Appearance of wound on day 10.

4b: Post debridement.

4c: Fish skin graft application.

4d: Post-operative day 8.

4e: Post-operative 15.

4f: Post-operative 25.

Results

Overall, the cohort of patients treated with FSG had an observed decrease in healing time, complications, and patient-reported pain. The clinical challenges encountered are outlined. Integration of the product ranged from day 8 - 15, with a phase of caramelization from day 3 - 7.

Conclusions

In this case study, the fish skin graft demonstrated comparable or better results to historic xenograft usage. Certain characteristics observed during and after wound closure indicate higher speed of product integration compared to standard of care products, reaching the same healing objectives in a shorter time. This allows for earlier physio therapy, hospital discharge or application of split thickness skin graft (STSG). Animal studies have shown that Omega-3 fatty acids in the fish skin graft have an inhibitory effect on bacterial growth, improve epithelial cell migration, angiogenesis and accelerated blood perfusion in the wound bed.4,5 The fish skin graft used has shown to be a safe, effective alternative, and has promising results as a non-mammal xenograft in burn care management. The almost complete preservation of its tissue characteristics during biologic processing may offer further benefits not yet identified in mammal alternatives and should be trialled in larger scale studies.

4d

4e 4f

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