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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 25  |  Issue : 1  |  Page : 48-51

Formal saline versus honey as escharotic in the conservative management of major omphaloceles


Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria

Date of Web Publication17-Apr-2018

Correspondence Address:
Prof. Christopher O Bode
Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_159_17

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  Abstract 

Background: The use of honey as an escharotic agent in the conservative management of omphalocele major has not been widely explored in spite of its proven benefits in chronic wound management. We explored the use of local honey as an escharotic agent by comparing its use with 2.5% formal saline in the conservative management of major omphaloceles at the Lagos University Teaching Hospital, Lagos, Nigeria. Methods: From January 2006 to December 2009, 43 consecutive newborns with intact omphalocele major were alternately assigned into either Honey (H) or formal saline (FS) group. The membrane cover of each omphalocele was painted with the allotted group agent once every 48 h. The occurrence of faecal fistulas, rupture of eschar, intestinal obstruction as well as the mean duration of full wound healing, infection rates and overall mortality rates were compiled for the two groups. Results: Eighteen newborns were assigned to the FS group while 25 others were prospectively enrolled into the H group. The age, sex and weight of newborns in both groups at presentation were comparable. Three omphaloceles (16.7%) ruptured and eviscerated among the FS group during the study while 1 (4%) of these occurred in the H group. Four (22.2%) cases of faecal fistula occurred in the FS group while none was recorded in the H group. One (5.6%) patient in the FS group developed small bowel stricture. This was not recorded in the honey group. Overall, there were 8 (44.4%) complications in the FS group and 1 (4%) in the H group. There was no statistical difference between the two groups concerning the occurrence of fistulae, sac rupture or bowel stricture. However, overall number of complications was statistically more in the FS group when compared to the H group (P < 0.05). Wounds in the H group healed within a mean period of 34.4 ± 4.9 days while those in the FS group healed within a mean period of 45.7 ± 6.8 days P < 0.01). Conclusion: Honey is a good escharotics agent in the conservative management of major omphaloceles. Honey promotes faster healing and unlike 2.5% formal saline, is not significantly associated with faecal fistulas, rupture or bowel stricture.

Keywords: Honey, omphalocele, paediatric


How to cite this article:
Bode CO, Ademuyiwa AO, Elebute OA. Formal saline versus honey as escharotic in the conservative management of major omphaloceles. Niger Postgrad Med J 2018;25:48-51

How to cite this URL:
Bode CO, Ademuyiwa AO, Elebute OA. Formal saline versus honey as escharotic in the conservative management of major omphaloceles. Niger Postgrad Med J [serial online] 2018 [cited 2020 Aug 5];25:48-51. Available from: http://www.npmj.org/text.asp?2018/25/1/48/230190


  Introduction Top


Omphalocele is the congenital herniation of abdominal contents into the base of the umbilical cord through an abdominal wall defect covered by a sac composed of amnion, Wharton's Jelly and peritoneum.[1] It constitutes one of the most common forms of anterior abdominal wall defect with an incidence of 3000 cases per live births. For treatment purposes, omphaloceles are classified as major and minor, based on the size of the fascial defect.[2]

The treatment options available depend largely on the size of the fascial defect and the presence of other congenital anomalies.[3] Those with the small defect are managed by the primary fascial closure. Larger defects may be managed by excision of the sac and staged reduction of the hernia content with a spring-loaded silastic silo before closure within 1–2 weeks to avoid the risk of the abdominal compartmental syndrome.[4] Such aggressive management of major omphaloceles requires mechanical ventilator support and total parenteral nutrition, often unavailable in resource-challenged third world settings. The use of escharotic agents to promote contraction and epithelisation has been widely reported with Mitul and Ferdous reporting a survival rate of 85% in their study.[5] A delayed repair is later performed for the resultant ventral hernia.[6] Many escharotics agents such as mercurochrome, methylated spirit and silver sulphadiazine have been employed for the initial management of major omphaloceles, with the aim of toughening the flimsy, non-living, protein-rich covering-membrane into a waterproof eschar under which granulation tissue may proliferate and eventually epithelise.[7] At the Lagos University Teaching Hospital, we had conventionally used a 2.5% formal saline (FS) preparation from our Pharmacy Department as escharotics. We have used honey for the management of other open wounds and have heard anecdotal reports of its use for omphaloceles. These prompted us to explore the possibility of employing this agent in the management of major omphaloceles and comparing it with our traditional use of FS.


  Methods Top


This was a cross-sectional analytical study that took place at the Lagos University Teaching Hospital. Ethical clearance was obtained for this study from the Hospital's Research Ethics Committee.

Inclusion criteria

All newborns with intact omphalocele major (fascial defect >5 cm) admitted into our service over 4 years period were alternately assigned into either Honey (H) or FS group.

Exclusion criteria

Excluded were cases of minor omphalocele which were primarily repaired, ruptured omphaloceles, grossly septic sacs, babies with omphaloceles from non-consenting parents and babies with life-threatening, co-existing gross pathologies such as severe cardiac defects.

Procedure

Bio-demographic details such as gestational age at delivery, birth weight and gender were obtained for each patient as well as the age at presentation. Clinical assessment of the patients included a systemic examination of the respiratory and the cardiovascular systems were performed to identify other co-morbidities. The membrane cover of each omphalocele was painted with the allotted group agent daily and was left open under a tent of insect-proof netting. The progressive separation of eschar from underlying granulation tissue was noted daily. Mean duration of full healing, the occurrence of faecal fistulas, rupture of eschar, intestinal obstruction and overall mortality rates were compiled for the two groups.

A restraining plaster cast was applied to the lower limbs to prevent the baby from kicking and rupturing the membrane in the early stages before the eschar had fully hardened. Oral feeding was commenced when alimentary continuity was assured. Each baby was treated with a 10-day course of augmentin (25–50 mg/kg/day) and multivitamin syrup. All the babies were admitted and treated on the same ward by the same group of nursing and medical staff. The data collated were analysed using SPSS software version 16 (SPSS Inc. Released 2007. SPSS Statistics for Windows, Version 16.0. Chicago, USA, SPSS Inc.).


  Results Top


Forty-three newborns were treated in the period under review. There were 24 (55.8%) males and 19 (44.2%) females, giving a male: Female ratio of 1.3:1. The age at presentation ranged from 1 to 8 days, with a mean age of 2.0 ± 1.4 days. Thirty-nine (90.7%) of the babies presented within the first 72 h of life, whereas the remaining 4 (9.3%) had been taken to other hospitals before presenting between 4–8 days. Eighteen newborns were assigned to the FS group while the remaining 25 were prospectively enrolled into the H group. The gender and age at presentation did not significantly differ between the FS and H groups.

Eschar separation from underlying granulation tissue

Separation of eschar from underlying granulation tissue occurred from 22 to 34 days in the FS group, with a mean of 29.9 ± 3.7 days. In the H group, the same occurred from 13 to 29 days, with a mean of 21.8 ± 5.7 days. The H group thus experienced a significantly earlier separation of eschar when compared to the FS group (P = 2.28−8).

Mean duration of full healing

Wounds in the H group healed within 27–45 days with a mean period of 34.4 ± 4.9 days while those in the FS group healed within 31–63 days with a mean period of 45.7 ± 6.8 days. Wounds in the honey group healed significantly earlier than the FS group (P = 0.0002). [Figure 1] and [Figure 2] showed patient whose omphalocele was managed with honey.
Figure 1: Early eschar separation with honey used as an escharotic. Note honey stain on the support padding

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Figure 2: Same patient at age 5 years, presenting for ventral hernia repair. Parents had absconded from outpatient clinic follow-up

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Sac rupture, Faecal fistula, Bowel stricture

Three omphaloceles (7%) ruptured and eviscerated among the FS group during the study while 1 (2.3%) of these occurred in the honey (H) group. Four (9.3%) cases of faecal fistula occurred in the FS group while none was recorded in the H group. One (2.3%) patient in the FS group developed small bowel strictures. These were resected at laparotomy and end-to-end anastomosis performed with a good outcome. No stricture was recorded in the honey group. Overall, there were 8 (18.6%) complications in the FS group and 1 (2.3%) in the H group. Although there was no statistical difference between the two groups concerning sac rupture or bowel stricture, the application of FS was statistically significantly associated with fistula formation (P = 0.017). Further use of FS was thus suspended after the eighteenth case [Table 1].
Table 1: Complication rates

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Mortality

Three babies died during the study. Two deaths resulted from faecal fistulas in the FS group and the third was from evisceration following a ruptured sac in the H group [Table 1] giving a mortality rate of 11.1% and 4%, respectively.


  Discussion Top


Many agents have been used as escharotics in the conservative treatment of major omphaloceles. Mercurochrome, silver sulphadiazine, methylated spirit and povidone-iodine have been applied to the friable omphalocele sacs for this purpose.[7],[8] The medicinal properties of honey have been known since ancient times and its healing effects have been employed for wound care since antiquity.[9] However, its use as an escharotic agent in the management of omphalocele has not been widely explored.

Our study revealed that the time of separation of eschar and the duration for complete epithelisation, converting the omphalocele sac to a ventral hernia was significantly shorter in the honey group than the FS group. A higher proportion of patients that were subjected to FS had their conditions complicated by bowel fistula and rupture of the sacs.

Nicoara et al.[10] reported the first ever use of Manuka honey in the conservative treatment of five cases of major omphaloceles. In this retrospective analysis of a limited case series, the investigators concluded that honey was safe, efficacious and it promoted wound healing with a favourable outcome. No untowards occurrence was ascribable to the use of honey in their study. The median duration for the full epithelisation in their study was 63 days as against a mean of 34.4 ± 4.9, obtained in our study. Only five patients were recruited in Nicoara's study, and this could explain the difference witnessed.

Honey has been shown to possess some inherent properties that make it a good healing agent.[11] It contains inhibin, a thermolabile, photolabile substance with antibacterial properties. It has a high nutrient content of fructose, sucrose, glucose, glucuronic acid and gluconolactone that combine to create an environment that promotes granulation tissue formation. Inhibin is essentially a composition of hydrogen peroxide, flavonoids and phenolic acid which results in shrinkage of bacterial wall. It also induces an unfavourable environment with a low pH level that further potentiates its antibacterial action.[11] In over 500 reports on the clinical usage of honey, no serious untowards effect of honey was documented.[12]

Although there is a paucity of literature on the use of honey in omphaloceles,[10],[13] its use in other surgical settings such as burn wound management and open wounds have been widely documented.[14] Subrahmanyam [15] found a higher rate in wound healing with the use of honey compared to silver sulphadiazine in a randomised controlled study. This finding is consistent with our study which revealed a comparatively shorter duration for full epithelisation than FS.

In a meta-analysis comparing the efficacy of honey in the management of burn wound with other conventional dressing agents and using the proportion of wound healed in 15 days as the outcome measure, Wijesinghe et al.[16] in their study reported a greater efficacy in the management of superficial and partial thickness burn wound with honey when compared to other alternative dressing treatment. Similarly, Molan [17] in an analysis of the use of honey as a wound dressing, concluded that there was convincing evidence to support the use of honey for a wide range of wounds because of its antibacterial, anti-inflammatory properties as well as its ability to promote granulation tissue. Bangroo et al.[18] also corroborated this finding in a review of the duration of healing of burn wounds in paediatric patients. The use of honey resulted in a shorter duration compared with sulphadiazine.

Limitation of the study

Bacteriological studies were not consistently available for the duration of this study. Moreso, we acknowledge that a major limitation of our study is the relatively small number of patients recruited and the alternate allocations of subjects into the study groups rather than following a randomisation schedule. Further work may thus be required on a much larger scale to generate a more statistically convincing outcome.


  Conclusion Top


Honey is a good escharotic agent in the conservative management of major omphaloceles and compared to 2.5% FS, honey promotes rapid formation of granulation tissue and gentle separation of eschar. It is not associated with faecal fistulas, rupture or bowel stricture. The use of honey as an escharotic therefore deserves further exploration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hin-Wing PL, Chun-Hung C, Hon-Lau H, A Review of 13 Cases of Exomphalos in Chinese. The Bulletin of the Hong Kong Medical Association. Available from: http://www.hkjo.lib.hku.hk/archive/files/9de2214479865f63b924b795160bbd82.pdf. [Last accessed on 2018 Mar 16].  Back to cited text no. 1
    
2.
Archampong EQ, Yeboa ED, Osei EK, Akafo S, Nkekyer K. Day surgery. In: Badoe EA, Archampong EQ, da Rocha-Afodu JT, editors. Principles and Practice of Surgery, Including Pathology in the Tropics. Accra: Assemblies of God; 2000. p. 494.  Back to cited text no. 2
    
3.
Swartz KR, Harrison MW, Campbell JR, Campbell TJ. Ventral hernia in the treatment of omphalocele and gastroschisis. Ann Surg 1985;201:347-50.  Back to cited text no. 3
[PUBMED]    
4.
Nicoll AE, Brechin S, Macara LM, Raine P, Cameron AD. Exomphalos in the West of Scotland (1987–2002). J Obs Gyn 2003;23:S1:38.  Back to cited text no. 4
    
5.
Saxena AK, van Tuil C. Delayed three-stage closure of giant omphalocele using pericard patch. Hernia 2008;12:201-3.  Back to cited text no. 5
    
6.
Mitul AR, Ferdous K. Initial conservative management of exomphalos major with gentian violet. J Neonatal Surg 2012;1:51.  Back to cited text no. 6
    
7.
Charlesworth P, Ervine E, McCullagh M. Exomphalos major: The Northern Ireland experience. Pediatr Surg Int 2009;25:77-81.  Back to cited text no. 7
    
8.
Eltayeb AA, Mostafa MM. Topical treatment of major omphalocoele: Acacia nilotica versus povidone-iodine: A randomised controlled study. Afr J Paediatr Surg 2015;12:241-6.  Back to cited text no. 8
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9.
Wikipedia on Honey. Available from: http://www.en.wikipedia.org/wiki/Honey. [Last accessed on 2017 May 18].  Back to cited text no. 9
    
10.
Nicoara CD, Singh M, Jester I, Reda B, Parikh DH. Medicated manuka honey in conservative management of exomphalos major. Pediatr Surg Int 2014;30:515-20.  Back to cited text no. 10
    
11.
Mandal MD, Mandal S. Honey: Its medicinal property and antibacterial activity. Asian Pac J Trop Biomed 2011;1:154-60.  Back to cited text no. 11
    
12.
Worldwide Wound, Honey As A Topical Antibacterial Agent for Treatment of Infected Wounds. Available from: http://www.worldwidewounds.com/2001/november/Molan/honey-as-topical-agent.html. [Last accessed on 2015 Jan 10].  Back to cited text no. 12
    
13.
Uba AF, Chirdan LB. Omphalocele and gastroschisis: Management in a developing country. Nig J Surg Res 2003;5;57-60.  Back to cited text no. 13
    
14.
Osman OF, Mansour JS, El-Hakim S. Honey compound for wound care: A preliminary report. Ann Burns Fire Disasters 2003;16:131-4.  Back to cited text no. 14
    
15.
Subrahmanyam M. A prospective randomised clinical and histological study of superficial burn wound healing with honey and silver sulfadiazine. Burns 1998;24:157-61.  Back to cited text no. 15
    
16.
Wijesinghe M, Weatherall M, Perrin K, Beasley R. Honey in the treatment of burns: A systematic review and meta-analysis of its efficacy. N Z Med J 2009;122:47-60.  Back to cited text no. 16
    
17.
Molan PC. The evidence supporting the use of honey as a wound dressing. Int J Low Extrem Wounds 2006;5:40-54.  Back to cited text no. 17
    
18.
Bangroo AK, Khatri R, Chauhan S. Honey dressing in paediatric burns. J Indian Assoc Pediatr Surg 2005;10:172-5.  Back to cited text no. 18
  [Full text]  


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]


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