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Vigneswaran Y, Hussain M, Varsanik MA, Corvin C, Gottlieb LJ, Alverdy JC. IDEAL Phase 2a Results: Posterior Rectus Sheath Flap for Hiatal Augmentation in Complex Paraesophageal Hernias. Ann Surg 2024; 279:1000-1007. [PMID: 38375674 PMCID: PMC11086674 DOI: 10.1097/sla.0000000000006247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
OBJECTIVE To report the developmental phase results of posterior rectus sheath hiatal flap augmentation (PoRSHA), a promising surgical innovation for large and recurrent paraesophageal hernias. BACKGROUND Durable hernia repair for large paraesophageal hernias continues to be a surgical challenge. PoRSHA addresses the challenges of current and historical approaches to complex paraesophageal hernias and demonstrates significant promise as a successful alternative approach. METHODS Using the IDEAL framework, we outline the technical modifications made over the first 27 consecutive cases using PoRSHA. Outcomes measured included hernia recurrence on routine imaging at 6 months and 2 years, development of a postoperative abdominal wall eventration and incidence of solid food dysphagia. RESULTS Twenty-seven patients at our single institution with type III (n=12), type IV (n=7), or recurrent (n=8) paraesophageal hernias underwent PoRSHA. Surgery was safely and successfully carried out in all cases. Stability of the technique was reached after 16 cases, resulting in 4 main repair types. At an average follow-up of 11 months, we observed no radiologic recurrences, no abdominal eventrations or hernias at the donor site, and 1 patient with occasional solid food dysphagia that resolved with dilation. CONCLUSIONS PoRSHA can not only be safely added to conventional hiatal hernia repair with appropriate training but also demonstrates excellent short-term outcomes. While the long-term durability with 5-year follow-up is still needed, here we provide cautious optimism that PoRSHA may represent a novel solution to the long-standing high recurrence rates observed with current complex PEH repair.
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Affiliation(s)
- Yalini Vigneswaran
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Mustafa Hussain
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - M. Alyssa Varsanik
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Chase Corvin
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Lawrence J. Gottlieb
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - John C. Alverdy
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
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Muylle E, Van De Winkel N, Hennion I, Dubois A, Thorrez L, Deferm NP, Pirenne J, Ceulemans LJ. Abdominal Wall Closure in Intestinal and Multivisceral Transplantation: A State-Of-The-Art Review of Vascularized Abdominal Wall and Nonvascularized Rectus Fascia Transplantation. Gastroenterol Clin North Am 2024; 53:265-279. [PMID: 38719377 DOI: 10.1016/j.gtc.2023.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Failure to close the abdomen after intestinal or multivisceral transplantation (Tx) remains a frequently occurring problem. Two attractive reconstruction methods, especially in large abdominal wall defects, are full-thickness abdominal wall vascularized composite allograft (AW-VCA) and nonvascularized rectus fascia (NVRF) Tx. This review compares surgical technique, immunology, integration, clinical experience, and indications of both techniques. In AW-VCA Tx, vascular anastomosis is required and the graft undergoes hypotrophy post-Tx. Furthermore, it has immunologic benefits and good clinical outcome. NVRF Tx is an easy technique without the need for vascular anastomosis. Moreover, a rapid integration and neovascularization occurs with excellent clinical outcome.
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Affiliation(s)
- Ewout Muylle
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Nele Van De Winkel
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Abdominal Surgery, University Hospitals Leuven, UZ Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Development and Regeneration, Unit of Urogenital, Abdominal and Plastic Surgery, KU Leuven, Leuven, Belgium
| | - Ina Hennion
- Tissue Engineering Lab, Department of Development and Regeneration, KU Leuven, KULAK Campus Kortrijk, Etienne Sabbelaan 53, bus 7711, 8500 Kortrijk, Belgium
| | - Antoine Dubois
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, UZ Herestraat 49, bus 708, 3000 Leuven, Belgium
| | - Lieven Thorrez
- Tissue Engineering Lab, Department of Development and Regeneration, KU Leuven, KULAK Campus Kortrijk, Etienne Sabbelaan 53, bus 7711, 8500 Kortrijk, Belgium
| | - Nathalie P Deferm
- Department of General and Abdominal Surgery, Sint-Franciscushospital, Pastoor Paquaylaan 129, 3550 Heusden-Zolder, Belgium
| | - Jacques Pirenne
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, UZ Herestraat 49, bus 708, 3000 Leuven, Belgium
| | - Laurens J Ceulemans
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium; Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.
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Abstract
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.
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Affiliation(s)
- Irum Amin
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Vigneswaran Y, Bryan AF, Ruhle B, Gottlieb LJ, Alverdy J. Autologous Posterior Rectus Sheath as a Vascularized Onlay Flap: a Novel Approach to Hiatal Hernia Repair. J Gastrointest Surg 2022; 26:268-274. [PMID: 34506032 PMCID: PMC8760196 DOI: 10.1007/s11605-021-05134-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/21/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Complex and recurrent paraesophageal hernia repairs are a challenge for surgeons due to their high recurrence rates despite the use of various prosthetic and suturing techniques. METHODS Here we describe the use of vascularized fascia harvested from the posterior rectus sheath with peritoneum during robotic hiatal hernia repair in two patients with large complex diaphragmatic defects. RESULTS Successful harvesting and onlay of the right posterior rectus sheath based on a falciform vascular pedicle was achieved robotically by rotating and securing the flap to the diaphragmatic hiatus as an onlay flap following cruroplasty of the hiatal defect. CONCLUSIONS In patients with difficult to repair large paraesophageal hernias, we demonstrate a promising new technique to restore the dynamic hiatal complex with the tensile strength of autologous vascularized fascia and peritoneum.
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Affiliation(s)
- Yalini Vigneswaran
- grid.412578.d0000 0000 8736 9513Sections of Minimally Invasive Surgery and Plastic Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, 5841 S Maryland Ave, MC5095, Chicago, IL 60637 USA
| | - Ava F. Bryan
- grid.412578.d0000 0000 8736 9513Sections of Minimally Invasive Surgery and Plastic Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, 5841 S Maryland Ave, MC5095, Chicago, IL 60637 USA
| | - Brian Ruhle
- grid.412578.d0000 0000 8736 9513Sections of Minimally Invasive Surgery and Plastic Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, 5841 S Maryland Ave, MC5095, Chicago, IL 60637 USA
| | - Lawrence J. Gottlieb
- grid.412578.d0000 0000 8736 9513Sections of Minimally Invasive Surgery and Plastic Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, 5841 S Maryland Ave, MC5095, Chicago, IL 60637 USA
| | - John Alverdy
- grid.412578.d0000 0000 8736 9513Sections of Minimally Invasive Surgery and Plastic Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, 5841 S Maryland Ave, MC5095, Chicago, IL 60637 USA
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Justo I, Marcacuzco A, Caso Ó, Manrique A, García-Sesma Á, Calvo J, García-Conde M, Fernández C, Del Pozo P, Rodríguez Y, Jiménez-Romero C. New technique for abdominal wall procurement. Initial experience. Clin Transplant 2021; 36:e14535. [PMID: 34783062 DOI: 10.1111/ctr.14535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/15/2021] [Accepted: 11/09/2021] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Iago Justo
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Alberto Marcacuzco
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Óscar Caso
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Alejandro Manrique
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Álvaro García-Sesma
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Jorge Calvo
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - María García-Conde
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Clara Fernández
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Pilar Del Pozo
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Yolanda Rodríguez
- Service of Pathology, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Carlos Jiménez-Romero
- Unit of HPB Surgery and Abdominal Organ Transplantation, "Doce de Octubre" University Hospital, Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
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Janssen Y, Van De Winkel N, Pirenne J, Ceulemans LJ, Miserez M. Allotransplantation of donor rectus fascia for abdominal wall closure in transplant patients: A systematic review. Transplant Rev (Orlando) 2021; 35:100634. [PMID: 34147948 DOI: 10.1016/j.trre.2021.100634] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/29/2021] [Accepted: 06/01/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Abdominal wall closure after intestinal, multivisceral or liver transplantation can be a major challenge. Different surgical techniques have been described to close complex abdominal wall defects, but results remain variable. Two promising transplant techniques have been developed using either non-vascularized or vascularized donor rectus fascia. This systematic review aimed to evaluate the feasibility, safety, and effectiveness of the two techniques. METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Human studies published between January 2000 and April 2020 were included. Methodological quality appraisal was done using an adapted 10-item standardized checklist. RESULTS The search resulted in 9 articles including 74 patients. Both techniques proved to be feasible and had similar results. After non-vascularized rectus fascia allotransplantation, there was a slightly higher rate of surgical site infections in the earlier reports. Overall, there were few complications, no fascial graft related rejections or deaths. The included articles scored low on quality appraisal, mostly due to the small number of cases and scarcely reported outcome parameters. CONCLUSIONS This systematic literature review reports two emerging new techniques for complex abdominal wall closure in transplant patients, with promising results. Standardized data collection in a prospective manner could give us more detailed information about short- and long-term outcomes. Preclinical animal studies are necessary for a thorough investigation of the mechanisms of graft integration, the risk of hernia development and the alloimmune response against the graft.
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Affiliation(s)
- Yveline Janssen
- Department of Abdominal Surgery, University Hospitals Leuven, Belgium
| | | | - Jacques Pirenne
- Leuven Intestinal Failure and Transplantation (LIFT), Department of Abdominal Transplant Surgery, Department of Microbiology, Immunology and Transplantation, University Hospitals Leuven, KU, Leuven, Belgium
| | - Laurens J Ceulemans
- Leuven Intestinal Failure and Transplantation (LIFT), Department of Thoracic Surgery, Department of Chronic Diseases and Metabolism, research consortium BREATHE, University Hospitals Leuven, KU, Leuven, Belgium
| | - Marc Miserez
- Department of Abdominal Surgery, University Hospitals Leuven, Belgium
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Baskaran V, Banerjee JK, Ghosh SR, Kumar SS, Anand S, Menon G, Mishra DS, Saranga Bharathi R. Applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery-a review of their utility and efficacy. Langenbecks Arch Surg 2021; 406:1249-1281. [PMID: 33411036 DOI: 10.1007/s00423-020-02031-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy. METHODS Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed. RESULTS The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy. CONCLUSIONS Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.
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Affiliation(s)
| | - Jayant Kumar Banerjee
- Department of Gastro-intestinal Surgery, Bharati Vidyapeeth Medical College, Pune, India
| | - Sita Ram Ghosh
- Department of Gastro-intestinal Surgery, Command Hospital (Eastern Command), Kolkata, India
| | - Sukumar Santosh Kumar
- Department of Gastro-intestinal Surgery, Command Hospital (Central Command), Lucknow, Uttar Pradesh, 226002, India
| | | | - Govind Menon
- Department of Plastic & Reconstructive Surgery, Command Hospital (Central Command), Lucknow, India
| | | | - Ramanathan Saranga Bharathi
- Department of Gastro-intestinal Surgery, Command Hospital (Central Command), Lucknow, Uttar Pradesh, 226002, India.
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Justo I, Marcacuzco A, Caso O, Manrique A, Calvo J, García-Sesma A, Nutu A, García-Conde M, Cambra F, Loinaz C, Jiménez-Romero C. Use of Nonvascularized Fascia in Liver Transplantation. Transplant Proc 2020; 52:1468-1471. [DOI: 10.1016/j.transproceed.2020.01.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/02/2020] [Indexed: 10/24/2022]
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Abdominal wall transplantation in organ transplantation: Our experience. Cir Esp 2019; 97:247-253. [PMID: 30948213 DOI: 10.1016/j.ciresp.2019.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/26/2019] [Accepted: 03/01/2019] [Indexed: 12/21/2022]
Abstract
Abdominal wall transplantation has been consolidated as an alternative to primary abdominal wall closure in intestinal and multiple organ transplant recipients. Given that it is feasible to obtain the visceral graft and the abdominal wall graft from the same donor, abdominal wall transplantation could offer satisfactory outcomes and be easily coordinated. Non-vascularized fascia is one of the alternatives for abdominal wall closure in transplantation. We report two cases of non-vascularized fascia transplantation in intestinal and multivisceral transplants, respectively. Both donors were young (23 and 18 years old). Both recipients had endured multiple previous surgeries, and no surgical alternatives for primary wall repair could be offered. In both cases, a complete abdominal wall flap was retrieved from the donor, however, due to the characteristics of the recipient's abdominal wall defect, only non-vascularized fascia was used after removing skin and subcutaneous cellular tissue from the graft. Abdominal wall transplantation is an option to consider for abdominal wall closure in patients with multiple previous surgeries and no alternatives for primary wall repair.
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Molitor M, Oliverius M, Sukop A. Abdominal wall allotransplantation. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 162:184-189. [PMID: 30209436 DOI: 10.5507/bp.2018.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/27/2018] [Indexed: 11/23/2022] Open
Abstract
Allotransplantation of vascularized composite tissue is a new field of transplantation surgery. One application of this technique is abdominal wall transplantation used as a supplementary procedure to the transplantation of visceral organs in patients with abdominal compartment deficits. As abdominal wall closure problems are experienced in around 30-40% of such patients, peer reviewed conclusions on the viability of various options, are important for an informed choice of possible procedures. This review focuses on the abdominal wall allotransplantion procedure. Our search provided 35 appropriate references which we used to support our findings as follows: abdominal wall transplantation was performed in 33 patients at seven centres. Of these, 30 had a full thickness abdominal wall transplanted from the same donor, 3 from a second donor. Three had visceral organ transplants and in addition, the posterior sheet of the rectus muscle fascia. In summary, our findings were that abdominal wall allotransplantation does not jeopardize the outcome of visceral organs transplantation. There is no higher risk of complications or rejection of the visceral organs. There have been no fatalities as a direct result of complications due to abdominal wall transplantation. Finally, the transplanted abdominal wall may provide an early warning of rejection before diagnostic tests on the bowel are symptomatic.
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Affiliation(s)
- Martin Molitor
- Department of Plastic Surgery Hospital na Bulovce and 1 st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Oliverius
- Department of General Surgery, 3 rd Faculty of Medicine, Charles University and Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Andrej Sukop
- Department of Plastic Surgery, 3 rd Faculty of Medicine, Charles University and Hospital Kralovske Vinohrady, Prague, Czech Republic
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12
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Techniques for abdominal wall reconstruction in intestinal transplantation. Curr Opin Organ Transplant 2017; 22:135-141. [DOI: 10.1097/mot.0000000000000394] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Reconstruction of Large Abdominal Wall Defects Using Neurotized Vascular Composite Allografts. Plast Reconstr Surg 2015; 136:728-737. [PMID: 26397250 DOI: 10.1097/prs.0000000000001584] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Abdominal wall vascularized composite allotransplantation is the second most common form of vascularized composite allotransplantation. Sensory and functional recovery are expected in other forms but have never been demonstrated in abdominal wall vascularized composite allotransplantation. The authors hypothesize that coaptation of two thoracolumbar nerves will result in reinnervation of the alloflap and maintenance of the muscle component. METHODS Adult, male, 10-week-old Brown Norway and Lewis rats were used for experiments. The rat donor's common iliac vessels were anastomosed to the recipient's femoral vessels. Intercostal nerves T10/L1 were coapted. Four groups (n = 5 per group) were included for study: group 1, Lewis, intercostal nerves cut, not repaired; group 2, Lewis intercostal nerves cut, T10/L1 repaired; group 3, allogeneic Brown Norway-to-Lewis abdominal wall vascularized composite allotransplantation, T10/L1 repaired; and group 4, syngeneic Lewis-to-Lewis abdominal wall vascularized composite allotransplantation, T10/L1 repaired. Animals were killed on postoperative day 60. Nerve regeneration was assessed using muscle weight analysis, myofibril cross-sectional area, nerve histomorphometry, and neuromuscular junction percentage reinnervation. RESULTS Groups 2, 3, and 4 maintained a significantly greater percentage of postharvest weight compared with group 1 (p < 0.05). Group 1 had significantly decreased myofibril cross-sectional area compared with controls (p < 0.05). There was no significant difference in myofibril cross-sectional area in groups 2 through 4 compared with controls (p > 0.05). Group 1 had significantly decreased percentage reinnervation of the alloflap compared with controls (p < 0.05). There was no significant difference when comparing group 2 through 4 with internal, contralateral controls (p > 0.05). CONCLUSION In a murine model for abdominal wall vascularized composite allotransplantation, coaptation of T10/L1 will allow for reinnervation of the alloflap and maintenance of the muscle component.
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15
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Chim H, Amer H, Mardini S, Moran SL. Vascularized composite allotransplant in the realm of regenerative plastic surgery. Mayo Clin Proc 2014; 89:1009-20. [PMID: 24996237 DOI: 10.1016/j.mayocp.2014.05.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 05/27/2014] [Accepted: 05/27/2014] [Indexed: 12/13/2022]
Abstract
Vascularized composite allotransplant (VCA) has led to new treatment options for patients with severe upper extremity and facial injuries. Although VCA can restore form and function, it exposes the patient to the risks associated with lifelong immunosuppression. Hopefully, ongoing advances in regenerative medicine will someday obviate the need for VCA, but until that time, VCA remains an immediate means of reconstructing otherwise unreconstructable defects. We review the outcomes of hand and face transplants, as well as the recent developments in immunosuppression as it relates to the field of VCA.
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Affiliation(s)
- Harvey Chim
- Division of Plastic Surgery & William J. von Liebig Transplant Center, Multidisciplinary Transplant Program, Mayo Clinic, Rochester, MN
| | - Hatem Amer
- Division of Plastic Surgery & William J. von Liebig Transplant Center, Multidisciplinary Transplant Program, Mayo Clinic, Rochester, MN
| | - Samir Mardini
- Division of Plastic Surgery & William J. von Liebig Transplant Center, Multidisciplinary Transplant Program, Mayo Clinic, Rochester, MN
| | - Steven L Moran
- Division of Plastic Surgery & William J. von Liebig Transplant Center, Multidisciplinary Transplant Program, Mayo Clinic, Rochester, MN.
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Chest wall, thymus, and heart vascularized composite allograft proof of concept cadaveric model for heart transplantation. Ann Plast Surg 2014; 73:102-4. [PMID: 24918739 DOI: 10.1097/sap.0000000000000181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of vascularized composite allografts allows for the reconstruction of complex scenarios that previously have required multistaged operations. Heart transplantation often follows a series of previous operations leading to chest wall deformities and significant mediastinal adhesions that can limit the use of larger hearts, making it difficult to find a suitable donor. Further, research has shown that the use of vascularized bone marrow and vascularized thymus in transplantation potentially prolongs graft survival with decreased immunosuppression requirements. The authors propose using a vascularized composite allograft of the chest wall consisting of sternum and thymus in conjunction with the heart for cardiac transplantation to allow for more flexibility from the donor pool, maintain chest wall integrity and physiology, and potentially immunoregulate the concomitant solid organ transplant.
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17
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Giele H, Bendon C, Reddy S, Ramcharan R, Sinha S, Friend P, Vaidya A. Remote revascularization of abdominal wall transplants using the forearm. Am J Transplant 2014; 14:1410-6. [PMID: 24797611 DOI: 10.1111/ajt.12724] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 02/11/2014] [Accepted: 02/23/2014] [Indexed: 01/25/2023]
Abstract
Primary abdominal wall closure following small bowel transplantation is frequently impossible due to contraction of the abdominal domain. Although abdominal wall transplantation was reported 10 years ago this, technique has not been widely adopted, partly due to its complexity, but largely because of concerns that storing the abdominal allograft until the end of a prolonged intestinal transplant procedure would cause severe ischemia-reperfusion injury. We report six cases of combined small bowel and abdominal wall transplantation where the ischemic time was minimized by remotely revascularizing the abdominal wall on the forearm vessels, synchronous to the intestinal procedure. When the visceral transplant was complete, the abdominal wall was removed from the forearm and revascularized on the abdomen (n = 4), or used to close the abdomen while still vascularized on the forearm (n = 2). Primary abdominal wall closure was achieved in all. Mean cold ischemia was 305 min (300-330 min), and revascularization on the arm was 50 min (30-60 min). Three patients had proven abdominal wall rejection, all treated successfully. Immediate revascularization of the abdominal wall allograft substantially reduces cold ischemia without imposing constraints on the intestinal transplant. Reducing storage time may also have benefits with respect to ischemia-reperfusion-related graft immunogenicity.
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Affiliation(s)
- H Giele
- Department of Plastic and Reconstructive Surgery, Oxford University Hospitals and University of Oxford, Oxford, United Kingdom
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Abstract
Abdominal wall defects requiring soft tissue coverage can be either partial-thickness defects or full-thickness composite defects. Soft tissue flap reconstruction offers significant advantages in defects that cannot be closed primarily. Flap reconstruction is performed in a single-stage procedure obviating chronic wound management. If the defect size exceeds the availability of local soft tissue for coverage, regional pedicled flaps can be delivered into the abdominal wall while maintaining blood supply from their donor site. Microsurgical free tissue transfer increases the capacity to provide soft tissue coverage for abdominal wall defects that are not amenable to either local or regional flap coverage.
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Affiliation(s)
- Donald P Baumann
- Department of Plastic Surgery, Unit 1488, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Houston, TX 77030, USA
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Berli JU, Broyles JM, Lough D, Shridharani SM, Rochlin D, Cooney DS, Lee WPA, Brandacher G, Sacks JM. Current concepts and systematic review of vascularized composite allotransplantation of the abdominal wall. Clin Transplant 2013; 27:781-9. [PMID: 24102820 DOI: 10.1111/ctr.12243] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2013] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Abdominal wall vascularized composite allotransplantation (AW-VCA) is a rarely utilized technique for large composite abdominal wall defects. The goal of this article is to systematically review the literature and current concepts of AW-VCA, outline the challenges ahead, and provide an outlook for the future. METHODS Systematic review of the literature was performed using MEDLINE, EMBASE, and PubMed to identify relevant articles discussing results of AW-VCA. Cadaver and animal studies were excluded from the systematic review, but selectively included in the discussion. RESULTS The resultant five papers report their results on AW-VCA(Transplantation, 85, 2008, 1607; Am J Transplant, 7, 2007, 1304; Transplant Proc, 41, 2009, 521; Transplant Proc, 36, 2004, 1561; Lancet, 361, 2003, 2173). These papers represent the result of two study groups in which a total of 18 AW-VCA were performed in 17 patients. Two different operative approaches were used. Overall flap/graft survival was 88%. No mortality related to the transplant was reported. One cadaver study and two animal models were identified and separately presented (Transplant Proc, 43, 2011, 1701; Transplantation, 90, 2010, 1590; Journal of Surgical Research, 162, 2010, 314). CONCLUSION Literature review reports AW-VCA is technically feasible with low morbidity and mortality. Functional outcomes are not reported and minimally considered. With advancements in vascularized composite allotransplantation research and decreasing toxicity of immunosuppression therapies and immunomodulatory regimens, AW-VCA can be applied in circumstances beyond conjunction with visceral transplantation.
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Affiliation(s)
- Jens U Berli
- The Department of Plastic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ravindra KV, Martin AE, Vikraman DS, Brennan TV, Collins BH, Rege AS, Hollenbeck ST, Chinappa-Nagappa L, Eager K, Cousino D, Sudan DL. Use of vascularized posterior rectus sheath allograft in pediatric multivisceral transplantation--report of two cases. Am J Transplant 2012; 12:2242-6. [PMID: 22594310 DOI: 10.1111/j.1600-6143.2012.04088.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Restoring abdominal wall cover and contour in children undergoing bowel and multivisceral transplantation is often challenging due to discrepancy in size between donor and recipient, poor musculature related to birth defects and loss of abdominal wall integrity from multiple surgeries. A recent innovation is the use of vascularized posterior rectus sheath to enable closure of abdomen. We describe the application of this technique in two pediatric multivisceral transplant recipients--one to buttress a lax abdominal wall in a 22-month-old child with megacystis microcolon intestinal hypoperistalsis syndrome and another to accommodate transplanted viscera in a 10-month child with short bowel secondary to gastoschisis and loss of domain. This is the first successful report of this procedure with long-term survival. The procedure has potential application to facilitate difficult abdominal closure in both adults and pediatric liver and multivisceral transplantation.
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Affiliation(s)
- K V Ravindra
- Department of Surgery, Duke University, Durham, NC, USA.
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