Techniques for abdominal wall reconstruction in intestinal transplantation

Closing the abdomen: update on the current surgical toolkit

PURPOSE OF REVIEW

Achieving abdominal wall closure after intestinal transplantation (ITx) is one of the crucial surgical challenges. This problem is present in 25-50% of all transplants due to reduction in abdominal domain, fistulae and extensive adhesions due to previous surgeries. Failure to achieve closure is an independent risk factor for mortality and graft loss. The aim of this paper is to summarize the current options to achieve this.

RECENT FINDINGS

Successful closure of the abdomen requires a tension-free repair. Primary closure of the fascia can be reinforced with synthetic or biological mesh. For more complex fascial defects bridging mesh, nonvascularised or vascularised rectus fascia can be utilised. If all components of the abdominal wall are affected, then a full-thickness abdominal wall transplantation may be necessary.

SUMMARY

A variety of successful techniques have been described by different groups to enable abdominal wall closure after ITx. Emerging developments in preoperative imaging, reconstructive surgery and immunology have expanded the surgical toolkit available. Crucial is a tailor-made approach whereby patients with expected closure issues are identified prior to surgery and the simplest technique is chosen.

New technique for abdominal wall procurement. Initial experience

Difficulty in obtaining adequate abdominal wall closure due to loss of the abdominal domain is a frequent complication of multivisceral, isolated intestinal transplantation and in some cases of liver transplantation. Various methods for primary closure have been proposed, including the use of synthetic and biological meshes, as well as full-thickness abdominal wall and non-vascularized rectus fascia grafts. We describe a novel technique for abdominal wall procurement in which the graft is perfused synchronously with the abdominal organs and can be transplanted as a full-thickness wall or as a non-vascularized rectus fascia graft. We performed six transplants of non-vascularized rectus fascia in three intestinal transplants, one multivisceral transplant, and two liver transplants. The size of the covered abdominal wall defects ranged from 17 cm × 7 cm to 25 cm × 20 cm. Only one patient developed graft infection secondary to enterocutaneous fistula requiring surgical correction and removal of the fascia graft. This patient, as well as two other patients, died due to sepsis. Our procurement technique allows removal of the rectus fascia graft to cover the abdominal wall defect, providing a feasible solution for treatment of abdominal wall defects in recipients after abdominal organ transplantation.

Using Radiographic Domain for Evaluating Indications in Abdominal Wall Transplantation

BACKGROUND

There is currently no description of abdominal domain changes in small bowel transplantation population or consensus of criteria regarding which patients are at high risk for immediate postoperative abdominal wall complications or would benefit from abdominal wall vascularized composite allotransplantation.

METHODS

A retrospective chart review was performed on 14 adult patients receiving intestinal or multivisceral transplantation. Preoperative and postoperative computed tomography scans were reviewed, and multiple variables were collected regarding abdominal domain and volume and analyzed comparing postoperative changes and abdominal wall complications.

RESULTS

Patients after intestinal or multivisceral transplantation had a mean reduction in overall intraperitoneal volume in the immediate postoperative period from 9031 cm3 to 7846 cm3 (P = 0.314). This intraperitoneal volume was further reduced to an average of 6261 cm3 upon radiographic evaluation greater than 1 year postoperatively (P = 0.024). Patients with preexisting abdominal wound (P = 0.002), radiation, or presence of ostomy (P = 0.047) were significantly associated with postoperative abdominal wall complications. No preoperative radiographic findings had a significant association with postoperative abdominal wall complications.

CONCLUSIONS

Computed tomography imaging demonstrates that intestinal and multivisceral transplant patients have significant reduction in intraperitoneal volume and domain after transplantation in the acute and delayed postoperative setting. Preoperative radiographic abdominal domain was not able to predict patients with postoperative abdominal wall complications. Patients with abdominal wounds, ostomies, and preoperative radiation therapy were associated with acute postoperative abdominal complications and may be considered for need of reconstructive techniques including abdominal wall transplantation.

The difficult abdominal closure after paediatric intestinal transplantation: Use of abdominal rectus muscle fascia and literature review

Primary abdominal wall closure after intestinal and multivisceral transplantation may not be possible because of loss of abdominal domain and/or graft size/abdominal cavity mismatch. Traditional closure techniques for the open abdomen may not be valid in these circumstances because of severe scarring of the abdominal wall from multiple previous surgeries in this particular group of patients. We present our initial experience with the use of non-vascularized abdominal rectus muscle fascia in two patients who underwent deceased donation and living-related combined liver and small bowel transplantation, respectively, and who could not be closed primarily. The donor fascia was attached to the recipient fascia in both patients. In either case, there was not enough skin cover for closure, the wound was left open, and a negative pressure dressing was applied. In both cases, over a period of 6 months after placement of the non-vascularized abdominal rectus muscle fascia, the wound contracted, granulation tissue gradually covered the wound, and healing occurred, giving an intact abdominal wall. The abdominal rectus muscle fascia from a deceased donor can be used in a definite procedure for closure of the abdominal wall either at the time of transplant or later when a suitable rectus muscle fascia graft becomes available.

Abdominal Wall Transplant Surgery

The evolution and success of intestinal and multi-visceral transplantation over the past 20 years have raised the issue of difficult or even impossible abdominal closure, a topic rarely encountered in other fields of transplantation. Different techniques have been proposed to address this topic. The choice depends on the transplant team's expertise and/or the availability of a plastic surgery service. Abdominal wall transplant is a type of composite tissue allograft that can be utilized to reconstitute the abdominal domains of patients who undergo intestinal transplant, and the results are encouraging. It is an effective option to achieve primary abdominal closure after intestinal transplant. In its full-thickness form, it may be useful for monitoring rejection or viability of visceral organs. Our aim is to review the role of abdominal wall transplant in achieving tension-free closure of the abdomen.

Small-for-size Syndrome Does Not Occur in Intestinal Transplantation Without Liver Containing Grafts

BACKGROUND

The ideal donor in intestinal transplantation (ITX) is generally considered to be 50% to 70% of recipient body weight. This may be due to concerns for "small for size" syndrome as seen in liver transplantation. We report our experience using smaller donors (donor-recipient weight ratio [DRWR], < 50%) in ITX recipients.

METHODS

We studied a group of ITX recipients with DRWR of 50% or less to unmatched controls who received intestinal allografts with DRWR greater than 50%. We examined patient and graft survival and enteral autonomy from parenteral nutrition as surrogate markers for safety of using smaller donors and ease of abdominal wall closure between groups to determine the value.

RESULTS

There was no difference in overall patient and graft survival, time to enteral autonomy from parenteral nutrition, and weight gain after ITX over time between groups. The need for complicated abdominal closure techniques was significantly more frequent in the control group than in the study group (34.6% vs 6.9%, P = 0.01). Secondary abdominal closure occurred more frequently in the control group (15.4% vs 0%, P = 0.014). Wound revisions also occurred more frequently in the control group (15.4% vs 0%, P = 0.028).

CONCLUSIONS

Our data suggest that ITX using smaller donors (DRWR ≤ 50%) seems to be an acceptable practice without adverse impact on surgical complications, nutritional autonomy, and patient and graft survival. Abdominal wall closure seems easier in recipients of smaller donors and "small for size" syndrome as described in liver transplantation does not occur with intestinal allografts.