Warfare-related complex abdominal wall reconstruction using a bioprosthetic regenerate template and negative pressure therapy

Warfare-related torso/abdominal wounds are often unique and complex and can pose a significant reconstructive challenge. The objective of this manuscript is to report the unique and successful management of a complex warfare-related abdominal wound. A dermal regenerate template in combination with negative pressure wound therapy was used to reconstitute lateral abdominal wall integrity after radical debridement and control of a necrotizing soft tissue infection of the torso. Adjunctive continuous negative pressure (vacuum assisted closure) therapy was used to provide external coverage and encourage the formation of granulation tissue. With this combination therapy, torso wound size decreased in surface area by 82% and the underlying musculofascial defect decreased by 64%. Neovascularization of a 55-cm(2) acellular dermal graft was achieved as evidenced by surface granulation and complete survival of a partial-thickness skin graft. In our patient with a complex war injury, advanced tissue replacement techniques and negative pressure wound therapy resulted in a decreased abdominal wall defect, a restoration of abdominal wall integrity/domain, and allowed for concurrent surgical treatment of complex intra-abdominal injuries.

Assessment of cadaveric organ viability during pulsatile perfusion using infrared imaging

Assessment of pulsatile perfusion (PP) is limited to measurements of flow (V) and resistance (R). We investigated infrared (IR) imaging during PP as a means for precise organ assessment. IR was used to monitor 10 porcine kidneys during 18 hr of PP in an uncontrolled Donation after Cardiac Death model. An IR camera (Lockheed Martin) was focused on the anterior surfaces of the kidneys. The degree of temperature homogeneity was compared with standard measurements of V and R. IR thermal images correlated with V and R (R=0.92, P<0.001). IR detected an increase in homogeneity during PP by comparing standard deviation differences before and after PP (P=0.002), which was not evident by standard measurements of V and R. Finally, IR assessment allowed for measurement of dynamic changes in perfusion.

Long-term graft survival after transplantation with kidneys from uncontrolled nonheartbeating donors

BACKGROUND

Notwithstanding the widely acknowledged organ-donor shortage coupled with the expanded waiting list for organs, many transplant programs have been reluctant to use kidneys from nonheartbeating donors. Some reasons expressed by those programs include a higher rate of delayed graft function, additional dialysis requirements, more medication usage, and inferior graft survival rates. To refute the common misperceptions, we reviewed our 4-year experience with 31 nonheartbeating donor kidneys recovered from uncontrolled donors (Maashticht classification) at our institution.

METHODS

After cardiac arrest and declaration of death, all donors underwent intravascular and intraperitoneal cooling. Immediately after bilateral en bloc nephrectomy, kidneys were placed on the Waters MOX pulsatile preservation machine. Preservation parameters were monitored hourly, using pharmacologic agents (Stelazine, dexamethasone, Humulin R) as indicated by those parameters.

RESULTS

The nonheartbeating donors ranged in age from 15 to 53 years, 83% were males, and 60% of deaths were caused by trauma. For the 21 recovered and transplanted at our center, delayed graft function occurred with 16 kidneys; there was no primary nonfunction. There was no obvious correlation between functional status and donor age. It was noted that the immediate-function kidneys had shorter warm ischemia and total preservation times compared with the delayed graft function group. Nineteen of the 21 grafts continue to function. All patients are surviving.

CONCLUSIONS

This series suggests that to obtain excellent results with nonheartbeating donor kidneys certain principles should be followed: use machine preservation to resuscitate and evaluate viability, choose immunologically low-risk recipients, avoid immediate exposure to immunophilin antagonists, and perform biopsy frequently for allograft dysfunction to exclude low-grade rejection.