The management of difficult abdominal closure after pediatric liver transplantation

An Alternative Abdominal Closure Technique After Pediatric Liver Transplant: Bogota Bag Technique

OBJECTIVES

In conditions such as large-for-size syndrome, postreperfusion hepatic edema, and intestinal edema, primary closure of the abdominal wall can cause respiratory complications and thrombosis of vascular structures. Here, we compared results of primary abdominal closure versus a temporary patch closure technique (the Bogota bag technique) in pediatric liver transplant recipients.

MATERIALS AND METHODS

We performed primary abdominal closure in 295 recipients. In 39 pediatric liver transplant recipients, the Bogota bag technique was used as the abdominal closure technique because of suspected intraoperative tense abdominal closure. In patients who had the Bogota bag technique, we sutured the sterilized saline bag to the skin at the edge of the defect by shaping the defect so as not to cause abdominal hypertension. Primary abdominal closure was achieved in patients after control laparotomies at 48-hour intervals.

RESULTS

The mean age of the primary abdominal closure group was 8.38 years, whereas the mean age of the Bogota bag group was 2 years. The average weight of patients in the primary abdominal closure group was 26.38 kg, and the average weight of patients in the Bogota bag group was 7.93 kg. Biliary atresia was the most common indication in both groups. Mean length of hospital stay was 21 days in the primary abdominal closure group and 24 days in Bogota bag group. Six patients in the Bogota bag group died from sepsis or bleeding in the early postoperative period. In the Bogota bag group, wound closure was achieved within 2 weeks in 25 patients and within 3 weeks in 8 patients.

CONCLUSIONS

Temporary patch closure techniques can be used safely in low-weight and young children, children with large-for-size grafts, and those who display increased intra-abdominal pressure.

Temporary Abdominal Closure Technique After Pediatric Liver Transplant: Single-Center Experience

OBJECTIVES

Primary abdominal wound closure is performed at the completion of liver transplant in most patients. However, this is not always possible in pediatric recipients. The shortage of size-matched donor organs for pediatric patients means that occasionally it is necessary to use whole livers that are larger than can be accommodated comfortably in the child's abdomen. The present report outlines our experience with temporary patch closure after pediatric liver transplant of the abdominal wall.

MATERIALS AND METHODS

Our team performed the first liver transplant in Turkey in 1988. Since 1988, we have performed 629 liver transplant (336 adult and 293 pediatric) procedures at our center. We evaluated data of 191 liver transplants performed in recipients who were under 10 years of age. Left lateral lobe grafts were used in 169 patients (88%), and whole grafts were used in 22 patients (12%).

RESULTS

Temporary closure with the Bogota bag patch was necessary in 31 transplant procedures (16.2%), 3 of which involved whole livers and 28 of which involved left lateral lobe grafts. The age range of recipients was 5 months to 10 years (median, 30 mo). The temporary abdominal closure technique was preferred in 22 patients because the abdomen could not be closed during surgery.

CONCLUSIONS

In pediatric patients with difficult abdominal closure after liver transplant, temporary patch closure is the treatment of choice. Our preference has been reinforced silicone sheeting, which allows minimal adhesion formation between the patch and abdominal viscera; in addition, the transparent nature of the material provides a window for inspection of the donor liver.

Monitoring intra-abdominal pressure after liver transplantation in children

IAH after LTX can impair perfusion and threaten graft viability. This study aimed to assess the feasibility of longitudinal IAP measurements as an IAH screening method in children after LTX. A cohort of 23 children with a mean age (range) 3.1 (3 months-14 years) who underwent LTX between May 2017 and February 2018 were evaluated retrospectively. Longitudinal IAP measurements were compared to bedside Doppler US monitoring data. In total, 425 IAP measurements and 257 US examinations were performed. The mean ± SD (range) time expenditure for IAP measurement was 1.9 ± 0.4 (0.5-3.2) minutes. The mean post-operative IAP was 7.9 ± 3.6 (1-25) mm Hg. IAH (IAP ≥ 10 mm Hg) was noted in 102 (24%) of 257 measurements. Agitation had a significant impact on IAP (estimate: 9.3 mm Hg, CI: 6.72-11.97, P < .01). In patients with TAC, IAP was increased (6.7 ± 2.1 vs 8.7 ± 3.1 mm Hg, P = .02) while peak portal venous velocities decreased (38 ± 27 vs 26 ± 22 cm/s, P = .03) after patch reduction. An abdominal compartment syndrome with severely impaired vascular flow was noted in one patient. Episodes of elevated IAP were noted in a large proportion of patients, underscoring the need for IAP monitoring in pediatric liver transplant recipients. The safety and low time expenditure associated with IAP measurement could be included easily into standard nursing procedures for these patients.

Use of vascularized posterior rectus sheath allograft in pediatric multivisceral transplantation--report of two cases

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.

Recognition and management of abdominal compartment syndrome among German pediatric intensivists: results of a national survey

INTRODUCTION

Several decades ago, the beneficial effects of goal-directed therapy, which include decompressive laparotomy (DL) and open abdomen procedures in cases of intra-abdominal hypertension (IAH) in children, were proven in the context of closures of abdominal wall defects and large-for-size organ transplantations. Different neonatologic and pediatric disease patterns are also known to be capable of increasing intra-abdominal pressure (IAP). Nevertheless, a considerable knowledge transfer regarding such risk factors has hardly taken place. When left undetected and untreated, IAH threatens to evolve into abdominal compartment syndrome (ACS), which is accompanied by a mortality rate of up to 60% in children. Therefore, the present study looks at the recognition and knowledge of IAH/ACS among German pediatric intensivists.

METHODS

In June 2010, a questionnaire was mailed to the heads of pediatric intensive care units of 205 German pediatric hospitals.

RESULTS

The response rate was 62%. At least one case of IAH was reported by 36% of respondents; at least one case of ACS, by 25%. Compared with adolescents, younger critically ill children appeared to develop IAH/ACS more often. Routine measurements of IAP were said to be performed by 20% of respondents. Bladder pressure was used most frequently (96%) to assess IAP. Some respondents (17%) only measured IAP in cases of organ dysfunction and failure. In 2009, the year preceding this study, 21% of respondents claimed to have performed a DL. Surgical decompression was indicated if signs of organ dysfunction were present. This was also done in cases of at least grade III IAH (IAP > 15 mmHg) without organ impairment.

CONCLUSIONS

Although awareness among pediatricians appears to have been increasing over the last decade, definitions and guidelines regarding the diagnosis and management of IAH/ACS are not applied uniformly. This variability could express an ever present lack of awareness and solid prospective data.

Abdominal decompression in children

Abdominal compartment syndrome (ACS) increases the risk for mortality in critically ill children. It occurs in association with a wide variety of medical and surgical diagnoses. Management of ACS involves recognizing the development of intra-abdominal hypertension (IAH) by intra-abdominal pressure (IAP) monitoring, treating the underlying cause, and preventing progression to ACS by lowering IAP. When ACS is already present, supporting dysfunctional organs and decreasing IAP to prevent new organ involvement become an additional focus of therapy. Medical management strategies to achieve these goals should be employed but when medical management fails, timely abdominal decompression is essential to reduce the risk of mortality. A literature review was performed to understand the role and outcomes of abdominal decompression among children with ACS. Abdominal decompression appears to have a positive effect on patient survival. However, prospective randomized studies are needed to fully understand the indications and impact of these therapies on survival in children.

Staged abdominal closure after small bowel or multivisceral transplantation

Following paediatric SBMT, size discrepancy between the recipient's abdomen and the graft may lead to ACS, graft dysfunction, and death. We report our experience with SAC in these patients. Between 04/1993 and 03/2009, 57 children underwent 62 SBMTs. When abdominal wall tension seemed excessive for safe PAC, SAC was performed, using a Silastic® sheet and a vacuum occlusive dressing. Transplantations with SAC (23 combined liver and small bowel [CLB]) were compared with those with PAC [14 ISB and 25 CLB]. Indications for transplantation, preoperative status (after stratification for ISB/CLB transplants), age at transplantation, donor-to-recipient weight ratio, reduction in bowel and/or liver, and incidence of wound complications were not different in both groups. Post-operative intubation, stay in intensive care unit, and hospital stay were prolonged after SAC. Two deaths were related to ACS after PAC, none after SAC. Since 2000, one-yr patient survival is 73% after ISB transplantation and 57% vs. 75% after CLB transplantation with PAC vs. SAC, respectively (NS). SAC safely reduces severe ACS after paediatric SBMT and can be combined with graft reduction for transplantation of small recipients.

Liver and vascularized posterior rectus sheath fascia composite tissue allotransplantation

Abdominal wall closure in pediatric solid organ recipients may be confounded by donor size discrepancy and structural insults from previous surgery. Here we describe the novel use of vascularized donor abdominal wall posterior rectus sheath fascia, as a composite tissue allotransplant (CTA), to achieve abdominal wall closure in a liver and double kidney pediatric recipient who could not be closed primarily due to donor/recipient size mismatch. The posterior rectus sheath fascia was procured in continuity with the liver and falciform ligament. Blood supply was achieved using the single hepatic artery anastomosis as part of the standard liver transplantation procedure. Specimens of posterior rectus sheath fascia taken on postoperative days 3 and 30 showed no signs of acute rejection. The patient succumbed to an overwhelming fungal infection on day 51, with no signs of intraabdominal involvement. The patient received no additional immunosuppression in conjunction with the posterior rectus sheath fascia allotransplant.

Reduction of left-lateral segment from living donors for liver transplantation in infants weighing less than 7 kg: technical aspects and outcome

LLS reduction has been frequently used in infants weighing <7 kg. Twenty recipients weighing <7 kg at the time of LDLT, median age 11.0 months and body weight 5.6 kg, were treated with an RLLS (n = 12) or LLS (n = 8) graft. Absolute indication of size reduction was that the estimated GRWR was >4.0%. Even if the preoperative GRWR was <4.0%, the RLLS graft was considered to ensure a size match. A flatfish-type LLS was preferred to a blowfish-type to make an RLLS graft for such a small infantile population. The RLLS recipients had significantly more flatfish-type grafts, while the LLS recipients had more blowfish-type grafts. Primary full-layer wound closure could be performed successfully in all LLS recipients, while in the RLLS group, two patients were forced to have partial skin closure. There were no graft losses related to graft compression. Reducing an LLS is a useful procedure to promote the comfortable accommodation of the graft in an infant weighing <7 kg. Flatfish-type LLS allowed more flexibility to make the suitable volume.

Liver transplantation in children with hyper-reduced grafts - a single-center experience

In small infants and babies who receive split or living-related adult left lateral segmental liver grafts, further reduction (hyper-reduction) of the graft may be necessary to optimize the size of the graft for the child. We report our experience with hyper-reduction of adult left lateral segment grafts in nine children. A retrospective review of the medical records of children who received hyper-reduced grafts at the Children's Hospital at Westmead, Australia was performed. Of 215 liver transplants performed on 186 children between 1986 and May 2009, 147 were reduced grafts. Nine grafts were further reduced (hyper-reduced) after an on-table assessment of graft size relative to the available abdominal space was made. Mean graft size reduction was by 30%. The pledgetted technique of resection was used in four patients. All required delayed closure of the abdomen, and in three patients, fascial closure was not possible and a Surgisis patch (Cook Surgical International, West Lafayette, IN, USA) was placed to augment the abdominal capacity. Two children had hepatic artery thrombosis. One was successfully thrombectomized. In the other, technical problems with the donor liver contributed to death 10 days post-transplant. Two bile leaks, one from the cut surface and the other at the anastomotic site, were oversewn at the time of abdominal closure. On follow-up (median 33 months), two developed biliary strictures requiring dilatation. Hyper-reduction of segmental grafts can be safely performed when needed. In view of its versatility, it may be preferable to hyper-reduce a graft rather than use a monosegment graft. Comparable long-term results are possible. The pledgetted technique of resection is easy, quick, and safe. The fact that it can be performed after revascularization with minimal blood loss adds great flexibility to this technically challenging procedure.

Repair of huge incisional hernias intentionally made during infantile living donor liver transplantation

BACKGROUND AND PURPOSE

In some small infants who are transplanted with a large-for-size graft by living donor liver transplantation, an incisional hernia is intentionally made to decrease the tension on the graft. The procedure and timing for repair of this type of hernia were retrospectively evaluated.

PATIENTS AND METHODS

Repair was carried out in 3 patients at 4 to 11 years after living donor liver transplantation. The preoperative, perioperative, and postoperative statuses were analyzed in each patient.

RESULT

Fascial closure was possible in all 3 patients. In 2 patients, separation of a component of the rectus sheath or a lower part of the major pectoral muscle was required for approximation of the fascia. One recipient had transient bile leakage that was treated successfully.

CONCLUSION

An intentionally made hernia should be as small as possible to facilitate easy primary closure at a later date. A procedure resembling the "clam-shell opening" method, which used a partly separated and extended sheet of the fascia, was feasible to avoid the requirement for an artificial mesh. Preschool ages may be suitable for easier approximation of the fascia.

Staged approach for abdominal wound closure following combined liver and intestinal transplantation from living donors in pediatric patients

Primary closure of the abdominal wall after combined liver and intestine transplantation from a living donor into a pediatric patient is usually not possible, because of the size of the donor organ, graft edema, and preexisting scars or stomas of the abdominal wall. Closure under tension may lead to abdominal compartment syndrome with vascular compromise and necrosis of the transplanted organ. We describe our experience of abdominal wound closure after liver and intestinal transplant in the pediatric patient using a staged approach. From February 2003 to June 2006, we managed five pediatric liver and intestinal living donor transplant recipients. Because of the large post-transplantation abdominal wall defect, a staged technique of abdominal wound closure was utilized. Initially, an absorbable Polygalactin mesh was sutured around the layer of the defect. As soon as adequate granulation tissue was formed over the mesh a STSG was applied. From the wound stand point all five patients were managed successfully with staged wound closure after transplantation. Granulation tissue filled and covered the mesh within 7.6 wk. A STSG was then used to cover the defect. All infants recovered well and none had a significant wound complication in the immediate post-operative period following STSG. At a mean follow-up of 24 months only one patient developed an entero-cutaneous fistula five months post-transplant. Staged abdominal wall coverage with the use of Polygalactin mesh followed by STSG is a simple and effective technique. A closed wound is achieved in a timely fashion with protection of the viscera. Residual ventral hernia will need to be managed in the future with one of several reconstructive techniques.

Incidence and management of abdominal wall defects after intestinal and multivisceral transplantation

BACKGROUND

Successful primary closure of the abdominal wall following visceral organ transplantation is not always feasible. Primary closure under tension can lead to fascial ischemia or necrosis, with subsequent dehiscence. Thus, alternate techniques to achieve abdominal wall closure are an important technical aspect in intestinal transplantation. The authors review their experience managing abdominal wall defects following intestinal or multivisceral transplantation.

METHODS

A retrospective review of the transplant database revealed 28 intestinal transplants in 24 patients from program inception in 1991 to January of 2002. The management of six intestinal transplant recipients with giant posttransplant abdominal wall defects is reviewed, and a novel technique is described for initially managing defects with prosthetic grafts that were serially reduced in size until a clean granulating bed was established, at which time they underwent permanent coverage using a meshed split-thickness skin graft.

RESULTS

Of the 28 transplants, primary fascial closure was possible in only 14. In the other 14 patients, the fascia could not be closed primarily at the time of transplantation. The donor weight-to-recipient weight ratio was significantly greater in patients with abdominal wall closure problems (0.64 versus 1.09; p < 0.005). The incidence of retransplantation was also higher in those with abdominal closure problems compared with those whose fascia could be closed primarily (five of 14 versus one of 14). The six patients managed with skin graft closure did not have any wound complications after grafting.

CONCLUSIONS

Abdominal wall defect after intestinal and multivisceral transplantation is a common problem without an ideal solution. Use of a skin graft on granulating abdominal viscera frozen with adhesions is a simple and reasonable solution to a complex problem.

Acellular dermal matrix provides a good option for abdominal wall closure following small bowel transplantation: a case report

Following small bowel transplantation (SBTx), approximating the midline abdominal fascia can be problematic in patients with severely retracted abdominal cavities. We first report the use of acellular dermal matrix (ADM) for abdominal closure following living related SBTx. A 44-year-old woman with ultra-short gut syndrome secondary to multiple bowel resections received a 160-cm segmental intestinal graft from her daughter. The graft ileocolic vessels were anastomosed end to side to the inferior vena cava and distal aorta. A terminal ileostomy was fashioned because the patient had previous panproctocolectomy. The graft perfused well, and the laparotomy was primarily closed. On postoperative day 1, the patient required surgical exploration for evacuation of hematoma. Due to graft edema in a significantly retracted abdominal cavity, a 12x7 cm fascia defect was evident. Leaving the abdomen open or using a mesh was not entertained as options due to the high risk of infections. Primary closure under tension would also jeopardize the transplant, increasing the risk of thrombosis. The fascia defect was closed using a segment of ADM. The patient did well and went home on the postoperative day 11. At 2-year follow-up she is well and on oral diet without fascia defect or incisional hernia. This is the first report of the use of ADM for abdominal closure in patients receiving a SBTx. ADM is considered safe when used in contaminated sites and can allow primary closure of difficult wounds often seen in SBTx patients.

Use of a bioengineered skin equivalent for the management of difficult skin defects after pediatric multivisceral transplantation

BACKGROUND

Primary wound closure is not always possible after pediatric multi-visceral transplantation because of oversized donor organs and/or intestinal or graft edema. We report our experience evaluating the safety and efficacy of Graftskin (Apligraf, Organogenesis, Canton, Mass), a bioengineered bi-layered human skin equivalent, for the management of difficult skin abdominal defects after multivisceral transplantation in a pediatric population.

METHODS

A retrospective chart review was performed of pediatric multivisceral transplantation patients who were treated with Graftskin. Adverse events, course of wound reepithelialization, and time for complete closure were recorded.

RESULTS

Four patients, 7 to 29 months old, were treated with Graftskin. One patient died because of unrelated reasons. Stimulation of the granulation, reepithelialization, and rapid reduction of the wound surface and depth occurred in the other 3 patients. Complete reepithelialization occurred within 5 months. No adverse events were noted.

CONCLUSION

Graftskin was a successful treatment for difficult abdominal skin defects after liver and multivisceral transplantation in children.

Use of a silastic silo for closure of the abdominal wall in a pediatric patient receiving a cadaveric split liver

Presented is the successful management of a difficult abdominal wall closure after pediatric liver transplantation. A 5-week-old boy with biliary atresia underwent urgent cadaveric split liver transplantation. The left lateral segment of an adult donor was utilized. Postoperatively, abdominal skin and fascia could not be closed. A SILASTIC (Dow Corning, Midland, MI) silo was applied, and complete closure was possible 6 days later.

Outcome of pediatric live-donor liver transplantation-the Toronto experience

BACKGROUND/PURPOSE

Live-donor liver transplantation (LDLT) has developed to address the critical shortage of cadaveric organs that accounts for 20% of children who die while awaiting for a liver transplant in Ontario each year. This report reviews the outcome of the pediatric recipients of LDLT at the authors' center.

METHODS

The charts of all children who received a LDLT between June 1996 and March 2002 were reviewed retrospectively.

RESULTS

Thirteen children (mean age, 3.6 years) underwent LDLT. All donors were parents except for one cousin. Ten grafts were left-lateral segments, 2 were right lobes, and 1 was a left lobe. Three patients required a SILASTIC((R)) (Dow Corning, Midland, MI) patch for delayed abdominal wall closure. Patient and graft survival rate was 100% with a median follow-up of 376 days. Major postoperative complications included biliary leaks (n = 2), biliary strictures (n = 1), portal vein thrombosis (n = 1), and hepatic venous complications (n = 1). There were no cases of hepatic artery thrombosis. Ten of 12 children became Positive for Epstein-Barr virus (EBV), and 3 of these patients had readily treatable post-transplant lymphoproliferative disorder.

CONCLUSIONS

LDLT is an acceptable alternative to cadaveric transplantation for children with end-stage liver disease.

Emergent abdominal decompression with patch abdominoplasty in the pediatric patient

BACKGROUND/PURPOSE

Abdominal compartment syndrome (ACS) is the cardiac, pulmonary, and renal dysfunction that occurs as a result of elevated intraabdominal pressure. The authors present their experience with patch abdominoplasty (PA) in pediatric patients as a means to treat and prevent ACS.

METHODS

The charts of patients who underwent PA were reviewed retrospectively. ACS was defined as the increased oxygen requirements and elevation of peak inspiratory pressures (PIP) associated with abdominal distension and worsening renal and or cardiac function.

RESULTS

A total of 23 patients (13 boys) were treated (average age, 23 months). Diagnoses included necrotizing enterocolitis (NEC, n = 13), trauma (n = 3), Hirschsprung's enterocolitis (n = 2), perforated bowel (n = 4), and bilateral Wilms' tumor with bowel obstruction (n = 1). Oxygen requirements decreased after patch abdominoplasty (mean preoperative FIO2, 0.87 +/- 24, mean postoperative, 0.67 +/- 24 [P = .01]). The PIP decreased significantly in the 13 patients who survived (mean preoperative PIP, 33 +/- 8, mean postoperative PIP, 27 +/- 7 [P = .01]). These PIPs failed to respond in the 8 nonsurvivors (mean preoperative PIP, 35 +/- 10, mean postoperative PIP, 33 +/- 14 [P value not significant]). Six of the 8 nonsurvivors had NEC. Complications of intraabdominal abscess and enterocutaneous fistula were seen in 5 patients, all of who had NEC.

CONCLUSIONS

Patch abdominoplasty effectively decreases airway pressures and oxygen requirements associated with ACS. Complications with PA occur primarily in patients with NEC. Failure to respond with a decrease in PIP and FIO2 requirements is an ominous sign.