["PLASTICS" DURING THE WAR OF "IRON SWORDS" - THE ROLE OF A SPECIALIST IN PLASTIC AESTHETIC AND RECONSTRUCTIVE SURGERY].

INTRODUCTION: A war usually requires a new or adjusted set up and needs of all caregivers according to the "new" status. The current war in Israel began on the 7.10.2023. The Israeli Ministries of Defense and Health were in a new status in which they had to complete new requirements according to the use of new weapons, and in numbers and types of injuries that overwhelmed the system from the day the war began. In the past, we published evidence that in times of terror, as in times of war, epidemiology of injuries changes and requires adjustments in human resources, surgical tools and consumables in the Israeli health and defense systems. This article aims to describe the role of specialists in plastic, aesthetic and reconstructive surgery and the first response according to the existing system divided into prevention, preparedness, response and rehabilitation. In the long term rapid response, recruitment of human resources, abilities and flexibility of the system enables overcoming a sudden "new" status as in war, terror and mass casualty events.

Personalised burn treatment: bedside electrospun nanofibre scaffold with cultured autologous keratinocytes: a case study.

Nearly four decades after cultured epidermal autografts (CEA) were first used for the treatment of extensive burn wounds, the current gold standard treatment remains grafting healthy autologous skin from a donor site to the damaged areas, with current skin substitutes limited in their clinical use. We propose a novel treatment approach, using an electrospun polymer nanofibrous matrix (EPNM) applied on-site directly on the CEA-grafted areas. In addition, we propose a personalised treatment on hard-to-heal areas, in which we spray suspended autologous keratinocytes integrated with 3D EPNM applied on-site, directly onto the wound bed. This method enables the coverage of larger wound areas than possible with CEA. We present the case of a 26-year-old male patient with full-thickness burns covering 98% of his total body surface area (TBSA). We were able to show that this treatment approach resulted in good re-epithelialisation, seen as early as seven days post CEA grafting, with complete wound closure within three weeks, and to a lesser extent in areas treated with cell spraying. Moreover, in vitro experiments confirmed the feasibility of using keratinocytes embedded within the EPNM: cell and culture viability, identity, purity and potency were determined. These experiments show that the skin cells are viable and can proliferate within the EPNM. The results presented are of a promising novel strategy for the development of personalised wound treatment, integrating on-the-spot 'printed' EPNM with autologous skin cells, which will be applied at the bedside, over deep dermal wounds, to accelerate healing time and wound closure.

Autoimmune dysautonomia in women with silicone breast implants.

IMPORTANCE AND OBJECTIVES: There is unmet medical need to understand the pathogenic mechanism of the panoply of clinical manifestations associated with silicone breast implants (SBIs) such as severe fatigue, widespread pain, palpitations, dry mouth and eyes, depression, hearing loss etc. We aimed to determine whether autoantibodies against the autonomic nervous system receptors can explain the enigmatic and subjective clinical manifestation reported by women with SBIs. RESULTS: Circulating level of autoantibodies against G protein-coupled receptors (GPCRs) of the autonomic nervous system (adrenergic, muscarinic, endothelin and angiotensin receptors) have been evaluated in symptomatic women with SBIs using an ELISA method. These women with SBIs addressed our clinic due to various subjective and autonomic-related manifestations such as chronic severe fatigue, cognitive impairment, widespread pain, memory loss, sleep disorders, palpitations, depression, hearing abnormalities etc. We report for the first time, a significant reduction in the sera level of anti-ß1 adrenergic receptor (p < 0.001), anti-angiotensin II type 1 receptor (p < 0.001) and anti-endothelin receptor type A (p = 0.001) autoantibodies in women with SBIs (n = 93) as compared with aged matched healthy women (n = 36). Importantly, anti-ß1 adrenergic receptor autoantibody was found to significantly correlate with autonomic-related manifestations such as: sleep disorders and depression in women with SBIs. CONCLUSIONS: Chronic immune stimulation by silicone material may lead to an autoimmune dysautonomia in a subgroup of potentially genetically susceptible women with SBIs. The appearance of autoantibodies against GPCRs of the autonomic nervous system serve as an explanation for the subjective autonomic-related manifestations reported in women with SBIs.

Bromelain-based enzymatic debridement of chronic wounds: Results of a multicentre randomized controlled trial.

Chronic wounds are estimated to affect over 6 million people annually in the United States with an estimated annual cost of $25 billion. Debridement represents a key step in their management and is considered a basic necessity to induce the functional process of tissue repair. However, there is an unmet need for an efficient rapid acting non-surgical debridement agent. Bromelain-based enzymatic debridement has been proven to provide an effective, selective and safe non-surgical debridement in deep burns. EscharEx (MediWound Ltd, Yavne, Israel), is a bromelain-based enzymatic debridement agent currently in development for chronic wounds. The aim of this study was to assess its safety and efficacy in chronic wounds. Seventy-three patients suffering from a lower extremity ulcer of diabetic/venous insufficiency/post-surgical/traumatic aetiology were enrolled in a multicentre, assessor blinded, randomized controlled trial. Patients were randomized to topical treatment by either EscharEx or its gel vehicle for up to 10 daily 4 hour applications, and then continued follow-up for up to 6 months. The EscharEx arm achieved a significantly higher incidence of complete debridement compared to the gel vehicle arm; 55 versus 29% (p = .047), thus meeting the primary endpoint of this study. The EscharEx and gel vehicle arms achieved similar reductions in wound area, non-viable tissue area and wound healing scores during the debridement period. There were no significant differences between the arms in the incidence of complete wound closure (41% in the EsxcharEx arm vs. 53% in the gel vehicle arm) and in the mean time to complete wound closure (70.0 ± 32.8 days in the EsxcharEx arm vs. 65.7 ± 38.4 days in gel vehicle arm). There were no significant safety issues and EscharEx demonstrated a favourable benefit to risk profile.

Conceptual Paper: Abdominoplasty and Liposuction in Systemic Sclerosis.

BACKGROUND: Surgical interventions in patients with systemic sclerosis (SSc), in particular plastic procedures, might cause undesired consequences. Notably, liposuction seems to possess greater risk as adipose tissue has been shown to play an important role in treating wounds and ulcers in patients with SSc. While anticentromere antibodies were found to be correlated with vasculopathy in SSc, patients with SSc and anticentromere antibodies might be more vulnerable to surgical wound complications following liposuction. A 46-year-old female patient, who had been diagnosed with SSc at the age of 31 years, had antinuclear as well as anticentromere antibodies. She underwent abdominoplasty with liposuction and developed severe skin necrosis of the abdomen following the procedure and at the site of liposuction. The correlation with anticentromere and the role of liposuction in skin necrosis in SSc are presented.

Standardization of Burn Patients Transfer: Implementation of a Transfer Request Form to Israel's National Burn Center.

BACKGROUND: Burn injuries are an extreme form of traumatic injury and are a global health issue. The Israeli National Burn Unit at the Sheba Medical Center, a tertiary level 1 trauma center and hence the national referral center, treats burn patients admitted both directly and referred from other medical centers. The transfer and handover of patients is a critical step in patient care. In Israel, to date, there is no standardized and accepted transfer request form for burn patients from one medical facility to another. OBJECTIVES: To construct a transfer request form to be used in all future burn patient referrals. METHODS: After reviewing publicly available international transfer forms and comparing them to the admission checklist used at our unit, a structured transfer request form was constructed. RESULTS: After a pilot study period, testing the form in various scenarios and adapting it, the first standardized transfer form for burn patients in Israel in both English and Hebrew was implemented beginning May 2020. CONCLUSIONS: Implementation of a standardized transfer process will improve communication between healthcare professionals to help maintain a continuum of care. We believe that implementation of a burn transfer form in all future referrals can standardize and assure better care for burn patients, thus improving overall patient care.

A Retrospective Review of an Off-label Bromelain-based Selective Enzymatic Debridement (Nexobrid®) in the Treatment of Deep, Partial, and Full Thickness Burns and Hard to Heal Wounds.

BACKGROUND: Rapid and selective bromelain-based enzymatic debridement provides a non-surgical alternative for the eschar removal in deep burns, which allows for early debridement of large surface areas, accurate evaluation of burn and wound depth, and the need for skin grafting. OBJECTIVES: To evaluate the efficacy of application of a bromelain-based selective enzymatic debridement (Nexobrid®) beyond the manufacturer's guidelines for use in burns > 48 hours as well as chemical, electrical, and pediatric burns, and chronic wounds. METHODS: This retrospective review included records collected between January 2017 and April 2019, from male and female patients aged 8 months to 99 years with deep burns or wounds treated with bromelain-based selective enzymatic debridement. RESULTS: Of the 33 patients who received the bromelain-based selective enzymatic debridement agent beyond the manufacturer's guidelines, 25 (76%) were observed to have successful debridement of the eschar, 8 (24%) were observed to have little effect on the burn eschar. Sixteen required further surgery after debridement. Clinical data on the use of bromelain-based selective enzymatic debridement agents are limited, but these results suggest the capacity to effectively debride burns > 48 hours (late presentation burns), use for pediatrics and for chemical and electrical burns, and apply to hard to heal full thickness chronic wounds. CONCLUSIONS: Bromelain-based selective enzymatic debridement was found to be an effective treatment modality beyond the recommended guidelines including late presentation burns and chronic wounds. This debridement method warrants further consideration when making clinical decisions concerning burn and wound care.

[MOHS MICROGRAPHIC SURGERY FOR CUTANEOUS MALIGNANT LESIONS EXCISION: EXPERIENCE OF A SINGLE TERTIARY MEDICAL CENTER IN ISRAEL].

AIMS: To review the literature, to present the experience with MMS of a single medical center in Israel and to compare findings to worldwide MMS trends. BACKGROUND: Mohs Micrographic Surgery (MMS) is a surgical technique that examines all of the cutaneous malignancy margins during surgery through precise mapping. This technique achieves the highest cure rates for cutaneous malignancies, while sparing normal tissue. The incidence of cutaneous malignancy is rising worldwide. The volume of Mohs surgeries increases as well. Therefore, physicians should gain knowledge about MMS utility in the treatment of cutaneous malignancy. This study is the first to be conducted is Israel and it aimed to present trends in the utilization of MMS. METHODS: A retrospective review of all MMS performed from 2012 to 2018 at the Sheba Medical Center. RESULTS: Overall, MMS technique was used in 3,795 cases. There was an upward trend in the utility volume of MMS during study period, from 372 cases in the year 2012 to 702 cases in 2017. We found an upward trend in the volume of MMS procedures within patients groups in the ages 65 to 74 and 75 years old and older. Male patients presented a double fold upward trend, in comparison to the female group. CONCLUSIONS: The upward trends found in this study correlate with the worldwide MMS trends and the rising incidence of cutaneous malignancy in Israel. More specialists are needed due to the increase in demand of MMS procedures.

[DIRECT TO IMPLANT IMMEDIATE BREAST RECONSTRUCTION USING THE FASCIAL SYSTEM IN THE INFRAMAMMARY FOLD, WITHOUT THE USE OF ACELLULAR DERMAL MATRIX].

AIMS: We present our experience of direct to implant breast reconstruction with total musculofascial coverage, without the use of ADM. BACKGROUND: The prevalence of one-stage breast reconstruction with silicone implants has increased markedly in recent years. This is attributed to advances in the surgical technique of mastectomy and to the increased rate of preventive mastectomy. The use of Acellular Dermal Matrix (ADM) became a common practice. Notwithstanding, ADM utilization may lead to higher postoperative complication rates. METHODS: Between 2015 to 2018, a prospective study was conducted at the Sheba Medical Center including all patients undergoing mastectomy and immediate breast reconstruction. In this study, we included patients who underwent direct to implant reconstruction with total musculofascial coverage, without the use of ADM. We gathered demographic, oncologic and surgical features, including post-operative complications, along with aesthetic outcome. RESULTS: A total of 20 patients (25 breasts) underwent direct to implant breast reconstruction with total musculofascial coverage. The overall complication rate was 24% (6 breasts). Minor complications (5 breasts, 20%) were manifested as delayed wound healing, minimal capsular contracture, skin necrosis and minor infection. A major complication of capsular contracture occurred in one patient. Corrective surgery due to aesthetic outcome was offered to 36% of the patients. nevertheless, only 16% chose to undergo an aesthetic reoperation. CONCLUSIONS: Immediate direct to implant breast reconstruction with total musculofascial coverage is an attractive option for single stage breast reconstruction with excellent aesthetic outcomes and low complication rates. Presumably, with a careful patient selection, the complication rates can be reduced even further.

A systematic review of Calendula officinalis extract for wound healing.

Use of complementary and alternative medicine for wound healing is influencing mainstream medical practice. This systematic review evaluates the role of Calendula officinalis flower extract as monotherapy compared to control for wound healing in vivo. Searches were conducted in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, and Scopus (up to April 2018) with 14 studies meeting the inclusion criteria, comprising 7 animal experiments and 7 clinical trials. Findings from the review on acute wound healing showed faster resolution of the inflammation phase with increased production of granulation tissue in the test groups treated with extract. These findings were consistent in five animal studies and one randomized clinical trial. Chronic wound healing studies were varied. Two clinical control studies on venous ulcers demonstrated decreased ulcer surface area compared to controls. Another randomized clinical trial demonstrated no improvement for the calendula group in diabetic leg ulcer healing. Burn healing similarly showed mixed results. Two animal studies demonstrated a prophylactic effect for the administration of calendula extract prior to burn injury. A randomized clinical trial of patients suffering from partial to full thickness burns demonstrated no benefit for topical application of calendula extract compared to controls. Two randomized clinical trials assessed the potential for extract to prevent acute post radiation dermatitis, with one study showing improvements compared to trolamine, while the other found no improvement compared to aqua gel cream. Animal studies provide moderate evidence for improved recovery from the inflammation phase and increased production of granulation tissue in calendula extract treatment groups. This review identified some evidence for the beneficial effects of C. officinalis extract for wound healing, consistent with its role in traditional medicine. There is a need for larger, well-designed randomized control trials to assess the effect of calendula on wound healing including complications.

Subcutaneous Injection of Tranexamic Acid to Reduce Bleeding During Dermatologic Surgery: A Double-Blind, Placebo-Controlled, Randomized Clinical Trial.

BACKGROUND: Topical application, oral, and IV injection of tranexamic acid (TXA) have been used to reduce surgical bleeding. OBJECTIVE: To evaluate the safety and efficacy of TXA injected subcutaneously to reduce bleeding during dermatologic surgery. METHODS: In this double-blinded, placebo-controlled, randomized prospective study, 131 patients were randomized to subcutaneous injection of lidocaine 2% diluted 1:1 with either saline (placebo) or TXA 100 mg/1 mL before surgery. Before the second stage or closure, size measurements of bloodstain impregnation on Telfa and surgical wound size were recorded and analyzed using mixed-effects linear regression. Subjective evaluation of hemostasis was performed using 4-point scale grading and analyzed using Fischer's exact test. RESULTS: One hundred twenty-seven patients completed the study. The bloodstain to surgical wound size ratio was smaller in the TXA group (1.77) compared with the placebo group (2.49) (p < .001). An improved effect of TXA on bleeding was observed in the subgroup of patients receiving anticoagulants (mean difference; 95% confidence interval; -0.83; -1.20 to -0.46 p < .001). The subjective hemostasis assessment was significantly better in the TXA group overall (p = .043) and anticoagulant subgroup (p = .001) compared with the placebo group. CONCLUSION: Subcutaneous injection of TXA was safe, reduced bleeding during dermatologic surgery, and particularly effective for patients receiving anticoagulation treatment.

Effect of Tight Glycemic Control Protocol on Hypoglycemia and Mortality in the Burn Unit: A Case-Control Study.

BACKGROUND: Burn injury pathophysiology is characterized by severe catabolic state and poor glycemic control. A tight glycemic control protocol using insulin for burn victims has yielded inconsistent mortality and morbidity outcomes. OBJECTIVES: To compare the effect of standard and tight glycemic control protocols on mortality and hypoglycemia events in critical care burn patients. METHODS: We conducted a case-control study of burn victims admitted to the burn intensive care unit between 2005 and 2011. Patients were assigned to either a standard or a tight glycemic control protocol. RESULTS: Of the 38 burn patients in the study, 28 were under a tight glycemic control protocol. No differences in glucose area-under-the-curve per day levels were observed between the groups (148.3 ± 16 vs. 157.8 ± 16 mg/dl in the standard and tight glycemic control protocol groups respectively, P < 0.12). The hypoglycemic event rate was higher in the tight glycemic control protocol group (46.4% vs. 0%, P < 0.008). No difference in mortality rate was noted (67.9% vs. 50%, P < 0.31). Mortality-independent risk factors found on multivariate analysis included total body surface area (adjusted hazard ratio [AHR] 1.039, 95% confidence interval  [95%CI] 1.02-1.06, P < 0.001), white blood cell count on admission (AHR 1.048, 95%CI 1.01-1.09, P < 0.02) and surgery during hospitalization (AHR 0.348, 95%CI 0.13-0.09, P < 0.03). CONCLUSIONS: The tight glycemic control protocol in burn patients was associated with higher rates of hypoglycemic events, and no association was found with improved survival in the acute setting of burn trauma care.

Purpose-built national burns center: The Israeli experience.

The opening of the National Burns Center (NBC) in Sheba Medical Center (SMC) in 2014 was a keystone point in the development of specialized burns trauma services for Israel to ensure burn care and disaster planning at international standards. The NBC is a purpose-built, level 1 burns trauma center that receives patients from Israel, Gaza, West Bank, and abroad. Hosting six intensive care and four step-down burns beds, the center serves as a referral center for patients in other health-care facilities with indication for hospitalization. In the present study, we describe the planning, design, and organization of the NBC at the SMC with reference to some of the key areas and considerations in its conception and development. With the improved survival rates of patients with extensive burns and the demographics and characteristics among burn-injury patients in Israel, the NBC has the capacity to be the center of excellence in burns care, teaching, and research within the Middle East.

Bromelain-based enzymatic debridement of chronic wounds: A preliminary report.

Sharp debridement is currently considered most effective for debridement of chronic wounds; however, some patients do not have access to or cannot be treated by surgical methods. This study was designed to provide a first impression of the safety and efficacy of bromelain-based enzymatic debridement of chronic wounds. Two consecutive single-arm studies assessing the enzymatic debridement efficacy of a concentrate of proteolytic enzymes enriched in bromelain in chronic wounds was conducted in 2 medical centres. Patients were treated with up to 11 consecutive 4-hour enzymatic debridement sessions and then treated until wound closure. Twenty-four patients with chronic wounds of different aetiologies were enrolled. All wounds achieved an average of 68% ± 30% debridement in an average of 3.5 ± 2.8 enzymatic debridement 4-hour sessions. Seventeen responding wounds (venous, diabetic, pressure, and post-traumatic aetiologies) achieved an average 85% ± 12% debridement in 3.2 ± 2.5 applications. Seven non-responding wounds (arterial and post-surgical aetiologies) achieved an average 26% ± 13% debridement in 4.3 ± 3.5 applications. No treatment-related serious adverse events were observed, and the only adverse event attributed to the enzymatic debridement was pain. These preliminary results indicate the potential safety and efficacy of bromelain-based enzymatic debridement in chronic wounds. Larger controlled studies are needed to further investigate this indication.

Q-Switched Nd:YAG Laser Removal of Facial Amateur Tattoos in Patients With Fitzpatrick Type VI: Case Series.

INTRODUCTION: Q-switched neodymium:YAG (Nd:YAG) lasers are reported to be gold standard for laser tattoo removal. In particular, the Q-switched Nd:YAG laser at 1064 nm is widely recognized for the removal of blue/black amateur tattoos. However, treatment modalities in Fitzpatrick Type VI skin carry a greater risk of complications including alterations in pigmentation compared to fairer skin (Fitzpatrick Type I-IV skin). Therefore, the aim of this case series was to describe with the use of the Q-Switched Nd:YAG laser, the removal of carbon-based amateur tattoos on patients with Fitzpatrick Type VI skin as an effective and safe method. METHODS: Twenty- five patients with Fitzpatrick type VI skin, from Ethiopian origins, with facial tribal tattoos, were treated with the Q- Switched Nd:YAG laser at 1064 nm. Digital images were taken upon every treatment and the clearance rates of the tattoo was evalu- ated by imaging software. RESULTS: We observed an average tattoo clearance rate of 95% among the 45 facial tattoos in 25 patients presented in the case series with minimal pigmentary and textual changes evident. DISCUSSION: These positive aesthetic results have a signi cant psychosocial impact on the lives of those with Fitzpatrick Type VI skin, in particular the Ethiopian Jewish population. J Drugs Dermatol. 2016;15(11):1448-1452..

The Impact of Autologous Fat Grafting on Breast Cancer: An Experimental Model Using Magnetic Resonance Imaging.

BACKGROUND: Although fat grafting is a common technique to repair defects after breast cancer reconstruction surgery and has a low complication rate, the relation between fat grafting and the risk of breast cancer is unknown. Clinical trials to investigate this connection can elucidate the benefits and potential risks of fat grafting in oncology patients. OBJECTIVES: To establish an efficient experimental model, using magnetic resonance imaging (MRI) scans, for comparing different breast tumor study groups post-fat grafting. METHODS: Breast tumor cells were injected into immunocompromised mice. After tumors formed they were removed. Liposuction was performed in a female human donor and fat was collected. Cells were extracted from the fat by enzymatic digestion. Immunocompromised mice were randomized into four groups: a preliminary experiment group and three equal groups according to the type of fat graft: (i) fresh fat enriched with adipose-derived mesenchymal stem cells (AdMSCs), (ii) fresh fat without cell enrichment, and (iii) no fat injected. Tumor volume was assessed by serial MRI scans. RESULTS: The rate of tumor growth was higher in the enriched fat group compared to the non-enriched fat group. CONCLUSIONS: This experimental model is an effective measurable method, allowing future investigation of the effect of autologous fat on breast cancer.

Adipocytes Viability After Suction-Assisted Lipoplasty: Does the Technique Matter?

BACKGROUND: Suction-assisted lipoplasty (SAL; liposuction) is an established aesthetic procedure in plastic surgery. The main parameters differentiating one method of lipoplasty from another are safety, consistency of results, and other more technical parameters. Due to the recent popularity of lipotransfer, the quality of extracted fat has become a relevant parameter. We compare the viability of extracted adipocytes after dry SAL, hyper-tumescent PAL (power-assisted lipoplasty), and water-assisted lipoplasty (WAL). METHODS: We used fluorescent microscopy to differentiate viable from necrotic/apoptotic cells after liposuction using each of the mentioned methods. RESULTS: The ratio of living cells between the three methods was significantly different with dry liposuction yielding inferior ratios (p = 0.011). When omitting extreme results, we found that the body-jet technique (WAL) yielded higher ratios of living cells than the hyper-tumescent technique (p < 0.001). The total number of cells was highest in the hyper-tumescent method (p = 0.013). CONCLUSIONS: Our results indicate that the hyper-tumescent technique yields the highest number of cells, whereas the body-jet technique yields the highest living cells ratio. The dry technique is clearly inferior to both. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[REVIEW OF 30 YEARS OF RESEARCH AND DEVELOPMENT OF AN ENZYMATIC DEBRIDEMENT AGENT FOR BURNS].

INTRODUCTION: Early removal of burn eschar is a cornerstone of burn care. The most commonly practiced eschar removal technique for deep burns in modern burn care is surgical debridement but this technique is associated with surgical burden and leads to unnecessary excision of viable tissue. GOALS: To review 30 years of research and development of an enzymatic debridement agent for burns. METHODS: Studies performed during the last 30 years are reviewed in this manuscript. RESULTS: Patients who underwent enzymatic debridement had a significantly shorter time to complete debridement, the surgical burden was significantly lower, hand burns did not necessitate escharotomy, and the long term results were favorable. DISCUSSION: Early enzymatic debridement leads to an efficient debridement, preservation of viable tissue, a reduction in surgical burden and favorable long term results. CONCLUSION: We believe early enzymatic debridement will lead to better care for burn victims and perhaps, even to a paradigm shift in the treatment of burns.

Secondary sclerosing cholangitis following major burn.

BACKGROUND AND AIMS: Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is a relatively new previously unrecognized entity which may lead to severe biliary disease with rapid progression to cirrhosis. We present for the first time a case series of patients with rapidly progressive SSC-CIP requiring aggressive intensive care treatment following major burn injury. RESULTS: SSC-CIP was diagnosed in 4 consecutive patients hospitalized due to major burn injuries at our Intensive Care Unit (ICU). SSC-CIP was diagnosed when ERCP (n = 1) or MRCP (n = 3) demonstrated irregular intrahepatic bile ducts with multiple strictures and dilatations and, when a liver biopsy (n = 3) demonstrated severe cholestasis and bile duct damage. All patients were males; none of whom had pre-existing liver disease. Ages: 18-56 y. All patients suffered from severe (grade 2-3) burn injuries with total burn surface area ranging from 35 to 95%. Mean length of ICU hospitalization was 129.2 ± 53.0 days. All patients required mechanical ventilation (with a mean PEEP of 8.4 ± 2.1 cm H2O) and the administration of catecholamines for hemodynamic stabilization. All patients demonstrated severe cholestasis. Blood cultures and cultures from drained liver abscesses grew hospital acquired multiple resistant bacteria. Liver cirrhosis developed within 12 months. One patient underwent orthotopic liver transplantation. Two patients (50%) died. In conclusion, SSC-CIP following major burn injury is a rapidly progressive disease with a poor outcome. Liver cirrhosis developed rapidly. Awareness of this grave complication is needed for prompt diagnosis and considerations of a liver transplantation.